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A  TEXT-BOOK 


OF  THE 


Practice  of  Medicine 


BY 


DR.  HERMANN  EJCHHORST 

Professor  of  Special  Pathology  and  Therapeutics  and  Director  of  the  Medical 
Clinic  in  the  University  of  Zurich 


AUTHORIZED  TRANSLATION  FROM  THE  GERMAN 


EDITED   BY 

AUGUSTUS  A.  ESHNER,  M.D. 

Professor  of  Clinical  Medicine  in  the  Philadelphia  Polyclinic  ;   Physician  to  the 

Philadelphia  Hospital ;  Assistant  Physician  to  the  Orthopedic 

Hospital  and  Infirmary  for  Nervous  Diseases 


Mitb  84  irilustrations 


VOLUME  I 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  &  COMPANY 

I90J 


GIFT 

Copyright,  1901,  by  W.  B.  SAUNDERS  &  COMPANY, 


Registered  at  Stationers'  Hall,  London,  England. 


ELECTROTVPEO    BY 
WESTCOTT   &   THOMSON,   PHILADA. 


PRESS  OF 
W.   B.   SAUNDERS  Sc  COMPANY. 


EDITOR'S   NOTE. 


For  those  who  read  German  no  introduction  to  Eichhorst^s 
Practice  of  Medicine  will  be  necessary ;  and  it  is  hoped  that  this 
translation  may  prove  not  less  useful  than  the  original,  and  as 
popular.  The  text  will  be  found  at  once  concise  and  compre- 
hensive, but  additions  and  annotations  have  been  made  where  it 
seemed  they  might  be  serviceable.  The  book  differs  somewhat 
from  most  other  works  on  the  practice  of  medicine  in  containing, 
among  other  things,  appropriate  sections  devoted  to  a  considera- 
tion of  Diseases  of  the  Skin,  the  Venereal  Diseases,  Impo- 
tence and  Sterility  in  the  Male,  and  Spermatorrhea.  A  number 
of  illustrations  have  been  added,  in  part  replacing,  in  part  sup- 
plementing, those  in  the  original.  The  book  has  been  written 
especially  to  meet  the  needs  of  tlie  student,  but  it  should  prove 
useful  also  to  the  busy  practitioner.  For  convenience  of  manipu- 
lation it  has  been^  deemed  wise  to  present  the  work  in  two 
volumes. 

AUGUSTUS  A.  ESHNER. 

Philadelphia,  March,  1901. 


PREFACE 


The  impulse  to  write  a  short  Text-book  of  Special  Pathology 
and  Therapeutics  has  not  emanated  from  myself,  but  from  my 
pupils.  For  a  number  of  years  the  latter  have  repeatedly  impor- 
tuned me,  and  all  references  to  existing  text-books  written  by  me 
were  in  vain.  Recently  the  demand  has  been  made  also  from 
distant  quarters,  and  I  have  therefore  finally  accepted  it  as  a  duty 
to  respond  to  a  request  pressed  with  such  persistence. 

The  governing  principle  in  the  preparation  of  this  work  was 
to  provide  the  student  with  a  book  that  should  afford  him  a  ready 
and  reliable  source  of  information  with  regard  to  the  principal, 
and  especially  to  the  most  important,  manifestations  for  the  recog- 
nition of  diseases.  As  the  essential  aim  of  the  physician  will  ever 
be  the  cure  of  disease,  earnest  consideration  has  been  given  to  the 
subject  of  treatment. 

Naturally,  this  text-book  can  deal  only  with  the  established 
facts  of  the  practice  of  medicine.  A  certain  degree  of  conciseness 
in  expression  and  in  description  also  was  demanded,  and  especially 
in  this  connection  considerable  difficulty  was  encountered  in  the 
effort  rigorously  to  separate  the  essential  from  the  unessential. 
In  how  far  I  have  been  successful  in  this  must  be  left  to  the 
decision  of  the  reader. 

Those  who  are  better  acquainted  with  the  manifestations  of 
clinical  medicine  will  find  the  necessary  elaboration  in  my  Hand- 
book of  Special  Pathology  and  Therapeutics.- 

I  shall  be  gratified  to  know  that  the  present  volume  will  real- 
ize the  expectations  of  those  for  whom  primarily  it  was  written. 

HERMANN  EICHHOEST. 

7 


CONTENTS   OF  VOLUME   I. 


PART  I.— DISEASES  OF  THE   CIRCULATORY   ORGANS. 

PAGE 

I.  Diseases  of  the  Myocardium 17 

"Weakness  of  the  Myocardium 17 

Dilatation  of  the  Heart ' 24 

Hypertrophy  of  the  Heart 28 

Fat  Heart  (Cor  Adiposum) 29 

Inflammation  of  the  Heart-muscle 31 

Tumors  of  the  Myocardium 33 

Echinococcus  of  the  Heart 34 

Dextrocardia 34 

Cardiorhexis 34 

II.  Diseases  of  the  Endocardium 35 

Acquired  Valvular  Disease  of  the  Heart 35 

Congenital  Heart-disease 45 

Inflammation  of  the  Endocardium 47 

Ulcerative  Endocarditis 47 

Verrucose  Endocarditis 49 

Thromhosis  of  the  Heart 51 

III.  Diseases  of  the  Pericardium 52 

Inflammation  of  the  Pericardium 52 

Pneumopericardium 58 

Dropsy  of  the  Pericardium 59 

Hemopericardium 60 

Chylopericardium 60 

Tumors  of  the  Pericardium 60 

IV.  Cardiac  Neuroses 61 

Paroxysmal  Tachycardia 61 

Paroxysmal  Bradycardia 63 

Cardiac  Intermittency 63 

Xervous  Heart-pain 68 

V.  Diseases  of  the  Aorta 65 

Aneurysm  of  the  Aorta     .    -        65 

Constriction  and  Occlusion  of  the  Isthmus  of  the  Aorta 71 

Embolism  of  the  Aorta 72 


PART  II.— DISEASES  OF  THE   RESPIRATORY  ORGANS. 

I.  Diseases  of  the  Nose 73 

]Srasal  Catarrh 73 

Fibrinous  Inflammation  of  the  Xasal  Mucous  Membrane     ....  77 

Hay-fever 77 

Mycosis  Xasi 79 

9 


10  CONTENTS  OF   VOLUME  I. 

PAGE 

11.  Diseases  of  the  Larynx v  .   .   .  79 

Catarrh  of  the  Larynx 79 

Edema  of  the  Glottis 85 

Inflammation  of  the  Perichondrium  of  the  Larynx 87 

Paralysis  of  the  Muscles  of  the  Larynx 89 

Spasm  of  the  Glottis 93 

Phonatory  Spasm  of  the  Glottis 94 

Sensory  Disorders  of  the  Laryngeal  Mucous  Membrane  .    .        .    .  95 

Laryngeal  Cough 95 

Mycosis  of  the  Larynx 96 

III.  Diseases  of  the  Trachea 96 

IV.  Diseases  of  the  Bronchi 96 

Bronchial  Catarrh 96 

Fibrinous  Bronchitis 103 

Bronchial  Dilatation 106 

Bronchial  Constriction Ill 

Bronchial  Asthma 113 

V.  Diseases  of  the  Lungs 117 

Alveolar  Emphysema  of  the  Lungs 117 

Interstitial  Emphysema  of  the  Lungs 120 

Atelectasis  of  the  Lungs 121 

Hypostasis  of  the  Lungs 122 

Edema  of  the  Lungs 123 

Catarrhal  Inflammation  of  the  Lungs 125 

Fibrinous  Inflammation  of  the  Lungs 128 

Interstitial  Pneumonia 139 

Suppuration  of  the  Lung    .        142 

Gangrene  of  the  Lung     .    .    .    .  • 144 

New-growths  of  the  Lung 149 

Echinococcus  of  the  Lung 151 

Aneurysm  of  the  Pulmonary  Artery 152 

VI.  Diseases  of  the  Pleura 152 

Inflammation  of  the  Pleura 152 

Pneumothorax 162 

Dropsy  of  the  Pleura 169 

Hemothorax 170 

Chylothorax 170 

Carcinoma  of  the  Pleura 170 

Echinococcus  of  the  Pleura 171 

VII.  Diseases  of  the  Mediastinum 171 

Mediastinal  Tumors 171 

Inflammation  of  the  Mediastinum 173 

Interstitial  Mediastinal  Emphysema 174 

PART  III.— DISEASES  OF  THE   DIGESTIVE  ORGANS. 

I.  Diseases  of  the  Mouth 175 

Catarrhal  Stomatitis 175 

Ulcerative  Stomatitis 177 

Aphthous  Stomatitis 178 

Thrush 179 

Leukoplakia  Oris 181 

Ptyalism 182 

II.  Diseases  of  the  Pharynx  and  the  Soft  Palate 184 

Catarrh  of  the  Pharynxand  the  Soft  Palate 184 

Mycosis  Pharyngis  Leptothricia 190 


CONTENTS  OF  VOLUME  I.  11 

PAGE 

III.  Diseases  of  the  Esophagus 191 

Carcinoma  of  the  Esophagus 191 

Diverticula  of  the  Esophagus 197 

Dilatation  of  the  Esophagus 199 

Catarrhal  Esophagitis       200 

Phlegmonous  Esophagitis 201 

Peptic  Ulcer  of  the  Esophagus 201 

Spontaneous  Rupture  of  the  Esophagus 202 

Softening  of  the  Esophagus 202 

Thrush  of  the  Esophagus 203 

Paralj'sis  of  the  Esophagus 203 

Spasm  of  the  Esophagus 204 

IV.  Diseases  of  the  Stomach 205 

Preliminary^  Considerations 205 

Acute  Gastric  Catarrh 210 

Chronic  Gastric  Catarrh 212 

Suppurative  Inflammation  of  the  Stomach 216 

Round  Ulcer  of  the  Stomach 217 

Carcinoma  of  the  Stomach 222 

Dilatation  of  the  Stomach 227 

Displacements  of  the  Stomach 233 

Gastric  Neuroses 234 

Motor  Gastric  Neuroses 234 

Nervous  Vomiting 234 

Nervous  Eructation 235 

Nervous  Regurgitation 235 

Peristaltic  Unrest  of  the  Stomach 236 

Hypermotility  of  the  Stomach 236 

Tonic  Spasm  of  the  Musculature  of  the  Stomach      .    .    .  236 

InsufBciency  or  Incontinence  of  the  Pylorus 237 

Rumination 237 

Atony  of  the  Stomach      238 

Sensory  Neuroses  of  the  Stomach 238 

Nervous  Gastralgia 238 

Disorders  of  the  Sense  of  Hunger  and  of  Satiety  ....  240 

Secretory  Neuroses  of  the  Stomach 240 

Hyperchlorhydria      240 

Anachlorhydria  and  Hypochlorhydria 240 

Hypersecretion  of  the  Gastric  Juice 241 

Mixed  Neuroses  of  the  Stomach 241 

Nervous  Dyspepsia 241 

V.  Diseases  of  the  Intestines 242 

Acute  Intestinal  Catarrh 242 

Acute  Gastro-intestinal  Catarrh  in  Infants 247 

Chronic  Intestinal  Catarrh      252 

Inflammation  of  the  Cecum  and  the  Vermiform  Appendix  and  the 

Surrounding  Tissues 257 

Round  Ulcer  of  the  Duodenum 266 

Carcinoma  of  the  Intestine 267 

Invagination  or  Intussusception  of  the  Bowel 271 

Stenosis  and  Obstruction  of  the  Bowel 275 

Hemorrhoids 284 

Melena  of  the  Newborn 288 

Enteroptosis 288 

Intestinal  Neuroses 289 

Motor  Intestinal  Neuroses 289 

Atony  of  the  Intestine 289 

Nervous  Diarrhea 290 

Peristaltic  Intestinal  Unrest 290 


12  CONTENTS  OF  VOLUME  I. 

.  PAGE 

Sensory  Intestinal  Xeuroses T  .    .    .  290 

Xervous  Spasm  of  the  Intestine 290 

Nervous  Enteralgia 291 

Animal  Parasites  of  the  Intestine 292 

Protozoa  in  the  Intestine 292 

"Worms  in  the  Intestine 293 

Flat  Worms 293 

Tapeworms 293 

Sucking  Worms 301 

Eound  Worms 301 

Spool  Worm ; 301 

Seat-worm 303 

Whip-worm .  30-i 

Trichina  Spiralis 305 

Ankylostomum  Duodenale 311 

Anguillula  Intestinalis  and  Anguillula  Stercoralis    .    .    .  315 

VI.  Diseases  of  the  Liver 315 

Jaundice      .......' 315 

Hypostatic  Liver 323 

Inflammation  of  the  Serous  Coat  of  the  Liver 325 

Suppurative  Hepatitis 327 

Chronic  Interstitial  Hepatitis 331 

Acute  Yellow  Atrophy  of  the  Liver 338 

Fatty  or  Adipose  Liver 342 

Amyloid  Liver 343 

Carcinoma  of  the  Liver 345 

Echinococcus  of  the  Liver 350 

Displacements  of  the  Liver 355 

Constricted  or  Fissured  Liver 356 

Diseases  of  the  Biliary  Passages         357 

Catarrh  of  the  Biliary  Passages 357 

Purulent  Inflammation  of  the  Biliary  Passages 359 

Dropsy  of  the  Gall-bladder 360 

Carcinoma  of  the  Biliary  Passages 361 

Parasites  in  the  Biliarv  Passages 361 

Gall-stones ' 362 

Diseases  of  the  Blood-vessels  of  the  Liver 368 

Thrombosis  of  the  Portal  Vein 368 

Purulent  Inflammation  of  the  Portal  Vein 370 

Aneurysm  of  the  Hepatic  Artery 370 

VII.  Diseases  of  the  Pancreas 371 

VIII.  Diseases  of  the  Peritoneum 372 

Inflammation  of  the  Peritoneum 372 

Abdominal  Dropsy ' 382 

Carcinoma  of  the  Peritoneum 386 

Echinococcus  of  the  Peritoneum 386 

PART  IV.-DISEASES  OF  THE  GENITO=URINARY  ORGANS. 

I.  Diseases  of  the  Kidneys 387 

Diagnostic  Preliminary  Considerations 387 

Albuminuria 387 

Hematuria 392 

Uremia         396 

Hypostatic  Kidney •  401 

DiflFuse  Nephritis 402 

Acute  Diftuse  Nephritis 402 

Chronic  Parenchymatous  Nephritis 409 

Chronic  Interstitial  Nephritis 411 


CONTENTS  OF  VOLUME  I.  13 

PAGE 

Purulent  Nephritis 416 

Embolic  Infarction  of  the  Kidney 420 

Amyloid  Kidney 421 

Carcinoma  of  the  Kidney 423 

Cystic  Kidney 425 

Echinococcus  of  the  Kidney 427 

Movable  Kidney 428 

Horseshoe  Kidney 432 

Absence  of  the  Kidney 432 

Inflammation  of  the  Pararenal  Connective  Tissue 432 

Aneurysm  of  the  Kenal  Artery 434 

II.  Diseases  of  the  Pelvis  of  the  Kidney  and  of  the  Ureter  .   .   .  435 

Dilatation  of  the  Pelvis  of  the  Kidney 435 

Inflammation  of  the  Pelvis  of  the  Kidney 438 

Kenal  Calculi          441 

Carcinoma  of  the  Pelvis  of  the  Kidney  and  the  Ureter 447 

Parasites  of  the  Pelvis  of  the  Kidney 448 

III.  Diseases  of  the  Urinary  Bladder 448 

Inflammation  of  the  Urinary  Bladder 448 

Carcinoma  of  the  Urinary  Bladder 455 

Parasites  of  the  Urinary  Bladder 457 

Foreign  Bodies  in  the  Urinary  Bladder 457 

Neuroses  of  the  Urinary  Bladder 458 

Nocturnal  Enuresis 458 

Hyperesthesia  of  the  Urinary  Bladder 460 

Spasm  of  the  Urinary  Bladder 460 

Paralysis  of  the  Urinary  Bladder 461 

IV.  Diseases  of  the  Male  Sexual  Organs 463 

Impotence  in  the  Male 463 

Sterility  in  the  Male 464 

Involuntary  Discharge  of  Seminal  Fluid 465 

True  Spermatorrhea 466 

Prostatorrhea      .• 468 

V.  Diseases  of  the  Adrenal  Bodies 468 

Addison's  Disease 468 


PART  v.— DISEASES  OF  THE  NERVOUS  SYSTEM. 

I.  Diseases  of  the  Peripheral  Nerves 472 

Peripheral  Paralysis 472 

Preliminary  Considerations 472 

Motor  Paralysis  of  the  Trigeminal  Nerve 476 

Paralysis  of  the  Facial  Nerve 477 

Paralysis  of  the  Spinal  Accessory  Nerve 488 

Paralysis  of  the  Hypoglossal  Nerve 489 

Multiple  or  Combined  Paralysis  of  Cerebral  Nerves     ....  490 

Paralysis  of  the  Phrenic  Nerve 490 

Paralysis  of  the  Radial  Nerve 492 

Paralysis  of  the  Median  Nerve 495 

Paralysis  of  the  Ulnar  Nerve 497 

Paralysis  of  the  Mu.«culocutaneous  Nerve 498 

Paralysis  of  the  Axillary  Nerve 498 

Combined  Parahsisof  the  Nervesof  the  Arm  and  the  Brachial 

Plexus  .   '. 498 


14  CONTENTS  OF   VOLUME  I. 

PAGE 

Peripheral  Paralysis  of  the  Scapular  Muscles     ...    .^  ... '  500 

Paralysis  of  the  Serrate  Muscle 500 

Paralysis  of  the  G-reater  and  Lesser  Pectoral  Muscles  .    .  503 
Paralysis  of  the  Ehomboid  and  the  Elevator  of  the  Angle 

of  the  Scapula 503 

Paralysis  of  the  Broad  Dorsal  Muscle 503 

Paralysis  of  the  Internal  Rotators  of  the  Arm 503 

Paralysis  of  the  External  Eotators  of  the  Arm  .        .    .    .  504 

Peripheral  Paralysis  of  the  Muscles  of  the  Back  .......  504 

Peripheral  Paralysis  of  the  Abdominal  Muscles     ......  504 

Peripheral  Paralysis  of  the  Crural  Xerve .    .  505 

Peripheral  Paralysis  of  the  Obturator  !Nerve 505 

Peripheral  Paralysis  of  the  Gluteal  Xerves 506 

Peripheral  Paralysis  of  the  Sciatic  Xerve •  .    .  506 

Periodic  Paralysis 507 

Spasmodic  Disorders  of  Motor  Xerves 507 

Motor  Trigeminal  Spasm .  507 

Spasm  of  the  Muscles  of  the  Face 508 

Spinal  Accessory  Spasm 510 

Hypoglossal  Spasm    . 510 

Spasm  of  the  Cervical  and  Scapular  Muscles  .    .......  511 

Spasm  of  the  Diaphragm ....  511 

Spasm  of  the  Abdominal  Muscles 512 

Muscular  Spasm  in  the  Upper  and  the  Lower  Extremities  .    .  513 

Cramps 513 

Neuralgia .  513 

Preliminary  Considerations 513 

Trigeminal  Neuralgia 516 

Cervico-occipital  Neuralgia 519 

Phrenic  Neuralgia ' 520 

Cervicobrachial  Neuralgia 520 

Dorso-intercostal  Neuralgia         520 

Lumbo-abdominal  Neuralgia 521 

Crural  Neuralgia 521 

Obturator  Neuralgia 522 

Neuralgia  of  the  External  Cutaneous  Nerves  of  the  Thigh  .    .  522 

Sciatic  Neuralgia 522 

Spermatic  Neuralgia 524 

Coccygodynia 524 

Articular  Neuralgia  .,.,.,,, 525 

Anesthesia 525 

Trigeminal  Anesthesia      ...        528 

Peripheral  Disease  of  the  Nerves  of  Special  Sense 529 

Disease  of  the  Olfactory  Nerve  .        529 

Disease  of  the  Gustatory  Nerve 530 

Inflammatory  and  Degenerative  Disorders  of  the  Peripheral  N  erves  .  531 

Preliminary  Considerations 531 

Multiple  Neuritis  .    .    .' .  534 

Toxic  Neuritis 536 

Saturnine  Paralysis 536 

Arsenical  Paralysis 538 

'  Alcoholic  Paralysis 539 

II.  Diseases  of  the  Spinal  Cord 540 

Preliminary  Diagnostic  Considerations     .    .            540 

Atypical  or  Asystematic  Diseases  of  the  Spinal  Cord 547 

Anemia  of  the  Spinal  Cord - 547 

Hyperemia  of  the  Spinal  Cord 548 

Hemorrhage  into  the  Spinal  Cord 548 

Acute  Inflammation  of  the  Spinal  Cord 552 

Chronic  Inflammation  of  the  Spinal  Cord 558 


CONTENTS  OF  VOLUME  I.  15 

PAGE 

Multiple  Cerebrospinal  Sclerosis 500 

Tumors  of  the  Spinal  Cord 5fi4 

Cavities  in  the  Spinal  Curd 564 

Spinal  Compression-paralysis 5f>7 

Unilateral  Lesions  of  the  Spinal  Cord 571 

System-diseases  of  the  Spinal  Cord 572 

Single  System-diseases 572 

Tabes  Dorsalis 572 

Spastic  Spinal  Paralysis 581 

Diseases  of  the  Ganglion-cells  of  the  Anterior  Horns  ....  582 

Acute  Spinal  Paralysis  of  Childhood 583 

Acute,  Subacute,  and  Chronic  Inflammation  of  the  Gan- 
glion-cells of  the  Anterior  Horns  in  Adults 586 

Spinal  Progressive  Muscular  Atrophy 588 

Combined  System-diseases  of  the  Spinal  Cord 592 

Hereditary  Ataxia 592 

Amyotrophic  Lateral  Sclerosis 593 

Functional  Disorders  of  the  Spinal  Cord  or  Xeuroses  of  the  Spinal  Cord  599 

Acute  Ascending  Spinal  Paralvsis 599 

Reflex  Paralysis ' 600 

Psychic  Paralysis 601 

Diseases  of  the  Spinal  Meninges 601 

Inflammation  of  the  Spinal  Dura  Mater 601 

External  Spinal  Pachymeningitis 601 

Internal  Spinal  Pachymeningitis       602 

Inflammation  of  the  Soft  Membranes  of  the  Spinal  Cord    ....  603 
Acute  Inflammation  of  the  Soft  Membranes  of  the  Spinal 

Cord 603 

Chronic  Inflammation  of  tbe  Soft  Membranes  of  the  Spinal 

Cord 606 

Hemorrhage  into  the  Spinal  Membranes 607 

Neoplasms  of  the  Spinal  Meninges 609 

Index  to  Volume  1 613 


CONTENTS   OF  VOLUME   II. 


Part  V.— DISEASES  OF  THE  NERVOUS  SYSTEM  (  ConimMec/). 

Part  VI.— DISEASES  OF  THE  MUSCLES. 

Part  VIL— DISEASES  OF  THE  SKIK 

Part  VIIL— DISEASES  OF  THE  SPEEN  AND  THE  BLOOD. 

Part  IX.— DISORDERS  OF  METABOLISM. 

Part  X.— INFECTIOUS  DISEASES. 


PART  I. 

DISEASES  OF  THE  CIRCULATORY 
ORGANS. 


I.   DISEASES  OF  THE   MYOCARDIUM. 


The  termination  in  cases  of  heart-disease  of  all  kinds  depends 
in  the  majority  upon  the  functional  capability  of  the  myocardium, 
and  death  occurs  in  most  cases  amid  manifestations  of  overwhelm- 
ing weakness  of  the  heart-muscle.  Easy  as  it  is  to  diagnose  con- 
ditions of  weakness  or  insufficiency  of  the  myocardium,  it  is  equally 
impossible,  as  a  rule,  to  recognize  during  life  the  anatomic  alterations 
that  have  taken  place  in  the  heart-muscle  itself  in  every  individual 
case.  The  anatomic  diagnosis  of  disease  of  the  myocardium  will 
not  reach  beyond  a  certain  degree  of  probability  even  under  favor- 
able conditions  ;  and  unfortunately  often  this  degree  is  not  obtained 
even  by  experienced,  observant,  and  careful  diagnosticians. 

The  diagnostic  scope  of  diseases  of  the  myocardium  is  thus 
most  circumscribed,  and  virtually  includes  only  three  conditions  : 
First,  that  of  weakness  or  insufficiency  of  the  myocardium,  already 
mentioned;  second,  enlargement  or  dilatation  of  the  heart;  and 
third,  increase  in  volume,  or  hypertrophy,  of  the  myocardium. 

WEAKNESS  OF  THE  MYOCARDIUM  (CARDIAC 
INSUFFICIENCY). 

Symptoms  and  Diagnosis. — The  symptoms  of  enfeeble- 
ment  of  the  myocardium  are  partly  local,  partly  general,  or  in 
many  instances  of  mixed  character. 

The  local,  or  strictly  cardiac,  manifestations  usually  attend  the 
onset.  The  action  of  the  heart  is  generally  accelerated  inordinately, 
and  at  the  same  time  it  is  usually  irregular.  While  at  first  these 
disturbances  perhaps  ovAy  follow  physical  and  mental  exertion, 
large  meals,  or  the  use  of  stimulants,  later  they  appear  also  during 
complete  rest  and  a  careful  mode  of  life,  lose  their  paroxysmal  char- 
acter, and  remain  permanent.  The  patient  often  complains  of  a 
sense  of  distressing  palpitation  of  the  heart,  at  times  also  of  a  feel- 

2  17 


18  CIRCULATORY  ORGANS 

ing  of  tension  and  pressure,  less  eonimonly  of"  a  painful  sensation 
in  the  region  of  the  heart,  suffers  from  shortness  of  breath,  and 
speaks  interrujitedly  and  at  short  intervals — staccato  speech. 

The  apcx-bcat  of  the  heart  appears  feel)le  or  is  not  palpable. 
The  .sounds  of  the  lieart  are  faint,  and  often  the  first  (systolic) 
sound  is  suggestive  of  a  murmur.  Not  rarely  f/a// op-rhythm  is 
present,  the  systolic  sound  of  the  heart  being  preceded  by  a  beat, 
the  accentuation,  however,  falling  upon  the  first  sound  itself.  As  a 
rule,  increase  in  the  area  of  cardiac  percnssion-dulneHS  to  the  right 
iuid  left,  in  consequence  of  dilatation  of  the  heart,  is  demonstrable. 

The  disturbances  of  cardiac  action  can  l)e  admiral )ly  studied 
in  the  radial  pulse.  This  attains  unusually  great  frequency,  ex- 
hibits very  unequal  waves,  and  is  irregular  and  frequently  also 
intermittent,  in  consequence  of  which  some  pulse-beats  become 
inappreciable,  because  the  foi^ce  of  the  heart  is  not  sufficient  to  send 
a  palpable  wave  of  blood  into  the  radial  artery  with  every  con- 
traction of  the  heart-muscle.  As  can  be  understood,  the  features 
of  a  frequent,  irregular,  unequal,  and  intermittent  pulse  will  appear 
also  in  the  sphygmographic  tracing  (Fig.  1). 


Fig.  1.— Sphyjnnographic  tracing  of  a  frequent,  irregular,  unequal,  and  intermittent 
ptulse  attending"  cardiac  weakness  In  consequence  of  a  valvular  lesion  (personal  observa- 
tion, Zurich  clinic). 

Only  rarely  are  the  consequences  of  weakness  of  the  heart- 
muscle  confined  to  the  local  or  cardiac  alterations  described,  and, 
as  a  rule,  general  disturbances  or  manifestations  of  stasis  appear  at 
the  same  time  or  more  frequently  somewhat  later. 

If  the  functional  activity  of  the  right  ventricle  is  impaired  to 
such  a  degree  that  it  is  no  longer  capable  of  sending  all  of  its 
blood  into  the  pulmonary  artery  M'ith  each  systole,  and  a  certain 
amount  of  blood  will  thus  remain  in  the  ventricle  after  each  sys- 
tole, the  flow  of  blood  from  the  right  auricle  will  first  be  inter- 
fered with,  and  at  the  same  time  also  that  from  the  superior  and 
inferior  vense  cava?  to  the  heart,  and  the  condition  of  general  venous 
stasis  becomes  estal)lished.  This  will  be  appreciable  earlier  and  in 
greater  degree  in  the  territory  drained  by  the  inferior  vena  cava, 
as  here  the  blood  must  be  propelled  against  the  force  of  gravity. 

H  with  weakness  of  the  heart-muscle  the  left  ventricle  is  espe- 
cially involved,  tlie  ultimate  result  is  nevertheless  the  same  as  that 
described.  At  first  blood-sta.-is  occurs  only  in  the  left  ventricle 
and  in  the  left  auricle,  but  from  these  it  extends  to  the  pulmonary 


WEAKNESS  OF  THE  .MYOCARDIUM  19 

veins,  the  pulmonary  capillaries,  the  pulmonary  arteries,  and  from 
these  in  turn  to  the  right  ventricle,  the  right  auricle,  and  the 
vense  cavse,  so  that  the  consequences  of  conditions  of  enfeeblement 
of  the  right  and  of  the  left  heart  are  the  same. 

Among  the  earliest  indications  of  general  venous  stasis  is  edema 
of  the  skin.  At  first  this  appears  on  the  inner  aspect  of  the  thigh 
and  aboxit  the  ankles.  At  this  time,  also,  it  frequently  recedes 
during  the  night,  thus  in  the  horizontal  position  of  the  body. 
Later,  however,  the  cutaneous  edema  becomes  persistent,  increas- 
ing in  extent,  and  advancing  with  progressive  stasis  to  the  geni- 
talia, to  the  posterior,  lateral,  and  inferior  portions  of  the  anterior 
aspect  of  the  abdominal  wall,  to  the  posterior  and  lateral  aspect 
of  the  chest,  to  the  arms,  and  even  to  the  face.  In  patients  accus- 
tomed to  lie  especially  on  one  side  of  the  body,  the  edema  of  the 
skin  is  also  more  marked  upon  that  side. 

If  edema  of  the  skin  has  existed  for  a  long  time  or  if  it  recur  persist- 
ently, a  thickening  of  the  cutis  takes  place,  especially  in  the  legs,  and 
elephantiasis  of  greater  or  less  degree  develops. 

In  addition  to  edema,  general  venous  stasis  gives  rise  to  cyano- 
sis of  the  shin  and  mucous  membranes.  This  is  due  to  the  fact  that 
with  retardation  of  the  blood-current  the  blood  gives  off  an  un- 
usually large  amount  of  oxygen  to  the  tissues,  and  at  the  same 
time  becomes  overladen  with  carbon  dioxid  from  them.  Lips, 
cheeks,  tip  of  the  nose,  ears,  elbows,  dorsa  of  the  hands,  knees, 
and  dorsa  of  the  feet  are  the  parts  in  which  cyanosis  of  the  skin 
appears  earliest  and  most  distinctly,  for  in  these  places  the  skin 
is  thin  and  at  the  same  time  rich  in  blood-vessels. 

On  the  cheeks  and  the  nose  dilatation  of  cutaneous  veins  frequently  takes 
place,  to  which  ultimately  chronic  inflammatory  hyperplasia  of  the  skin 
may  gradually  be  superadded,  so-called  acne  rosacea. 

On  palpation  reduction  of  the  temperature  of  the  skin,  is  generally 
apparent,  and  this  may  be  explained  by  the  fact  that  with  retar- 
dation of  the  blood-current  unusually  active  cooling  of  the  blood 
can  take  place. 

Obstruction  to  the  flow  of  blood  from  the  renal  veins  into 
the  inferior  vena  cava  gives  rise  to  manifestations  of  hypostatic 
(cyanotic)  kidney  and  the  urine  of  stasis.  The  urine  is  voided  in 
diminished  amount  (less  than  1500  c.c),  and  is  characterized  by 
its  dark-red  (high,  saturated)  color  and  high  specific  gravity  (above 
1017);  it  exhibits  an  acid  reaction,  frequently  contains  small 
amounts  of  albumin  and  hyaline  tube-casts,  and  often  on  cooling- 
deposits  a  red,  brick-dust-like  (lateritious)  sediment,  which  consists 
principally  of  acid  urates,  and  mainly  of  acid  sodium  urate.  On 
microscopic  examination  this  appears  in  the  form  of  irregularly 
distributed  granules.  Increase  and  diminution  in  venous  stasis 
are  accurately  reflected  in  the  state  of  the  urine. 


20  CIRCULATORY  ORGANS 

Naturally  stasis  of  the  blood  in  the  inferior  vena  cava  will 
also  interfere  with  the  discharge  of  blood  from  the  hepatic  veins, 
and  will  consequently  give  rise  to  the  Jn/pos(atlc  (cj/anofic)  liver. 
Under  such  conditions  the  liver  increases  in  size,  so  that  its  lower 
border  may  reach  to  the  level  of  the  umbilicus  or  still  lower.  The 
organ  is  sensitive  on  palpation  and  unusually  hard.  The  patients 
also  eoniplain  frequently  of  a  sense  of  tension  or  pressure,  or  even 
of  pain,  as  well  as  of  constriction  in  the  region  of  the  liver.  Xot 
rarely  hypostatic  catarrh  of  the  biliary  passages  develops,  with 
the  appearance  of  jaundice  (icterus),  which  is  frequently  confined 
to  the  ocular  conjunctivae,  but  at  times  involves  also  the  general  cuta- 
neous integument.  If  cyanosis  be  present  in  addition  to  icterus, 
the  skin  frequently  acquires  a  slight  greenish  tint,  icterus  viridis. 

Venous  stasis  generally  extends  from  the  area  of  the  hepatic 
veins  to  that  of  the  portal '  vein,  and  accordingly  symptoms  of 
stasis  referable  to  the  stomach,  the  intestine,  the  spleen,  and  the 
pentoneum  will  appear.  Stomach  and  bowel  become  the  seat  of 
hypostatic  catarrh,  characterized  by  loss  of  appetite,  eructation, 
vomiting,  flatulent  distention  in  the  epigastrium,  and  irregularity 
in  evacuation  of  the  bowels.  Dilatation  of  the  hemorrhoidal 
veins  also  not  rarely  takes  place,  and  hemorrhoids  form.  The 
spleen  becomes  increased  in  size,  and  in  still  greater  degree  in 
consistency,  and  very  considerable  amounts  of  transudate  often 
collect  in  the  abdominal  cavity  (ascites). 

The  thoracic  viscera,  also,  l^ecome  involved  in  the  manifesta- 
tions of  stasis.  The  patients  often  suiFer  from  obstinate  hypostatic 
catarrh  of  the  bronchi.  Xot  rarely  expectoration  of  blood  (hemopty- 
sis)  takes  place,  in  consequence  at  times  of  rupture,  at  other  times 
of  embolic  occlusion,  of  blood-vessels.  On  microscopic  examina- 
tion of  the  sputum  cells  diffusely  stained  with  hemoglobin,  or 
containing  hemoglobin  in  the  form  of  granules,  needles,  and  even 
plates  or  tables,  are  frequently  found.  These  are  improperly 
designated  heart-failure  cells,  although  they  occur  also  in  associa- 
tion with  other  diseases,  for  instance  fibrinous  pneumonia,  and 
they  are  believed  to  be  in  part  alveolar  epithelium  and  in  part 
round  cells.  The  pleural  cavities  l)ecome  filled  with  transudate 
(hydrothorax).  Similar  changes  take  place  in  the  pericardium,  and 
hyd roper icardiuni  is  frequently  observed. 

Evidences  of  venous  stasis  are  found  also  in  the  distribution  of 
the  jugular  veins.  These  veins  themselves  are  conspicuous  on 
either  side  of  the  neck  by  reason  of  their  unusual  fulness  and 
dilatation.  The  patients  suffer  from  hypostatic  catarrh  of  the 
pharync/eal  and  nasal  mucous  membrane,  and  at  times  from  fre- 
quent epistaxis.  Some  complain  of  tinnitus  aurium  and  impair- 
ment of  hearing.  At  times  the  eyes  protrude  markedly,  and  in 
consequence  of  over-distention  of  the  retrobulbar  veins  slight 
exophthalmos    becomes  appreciable.      The    blood-vessels  of   the 


WEAKNESS  OF  THE  MYOCARDIUM  21 

conjunctiva  appear  dilated  and  tortuous,  and  often  excessive  lac- 
rimal secretion  accumulates  in  the  conjunctival  sacs. 

Many  patients  complain  of  vertigo,  introspectiveness,  cerebral . 
pressure,  disturbed  sleep,  and  the  like,  which  are  related  to  venous 
hyperemia  of  the  brain. 

The  duration  and  the  course  of  weakness  of  the  heart-muscle 
depend  in  every  instance  upon  the  operative  causes.  If  these  can 
be  quickly  removed,  the  manifestations  of  myocardial  weakness 
likewise  frequently  recede  within  a  short  time.  Naturally  the 
condition  must  not  have  progressed  too  far,  for  then  the  danger 
will  be  great  that  to  heart-weakness  will  be  added  paralysis  of  the 
heart  Frequently  the  causes  can  only  be  temporarily  removed  or 
diminished,  and  accordingly  the  signs  of  myocardial  weakness 
recur  again  and  again.  Many  patients  die  in  consequence  of 
excessive  hi/postatic  jjhenoviena,  for  when  accumulations  of  con- 
siderable amounts  of  transudate  have  taken  place  in  the  peritoneal, 
pleural,  and  pericardial  cavities  there  is  danger  that  heart  and 
lungs  will  be  impeded  in  their  movement  to  so  high  a  degree  that 
the  maintenance  of  life  is  impossible.  Only  rarely  does  death 
take  place  in  consequence  of  unrestvainable  pidmonary  hemorrhage. 
Excessive  edema  of  the  skin  also  is  attended  with  danger  to  life,  as 
the  skin  may  rupture  at  various  points,  and  thus  permit  of  the 
escape  of  edematous  fluid.  Infection  with  bacteria  from  the  air 
may  then  readily  take  place,  and  give  rise  to  an  erythematous  or 
erysipelatous  inflammation  of  the  skin,  and  general  septicemia  may 
lead  to  a  fatal  termination.  In  some  cases  intercurrent  accidents 
take  place,  and  pneumonia  especially  not  seldom  occurs. 

Chronic  states  of  heart-weakness  are  among  the  most  distress- 
ing conditions,  and  they  may  compel  the  patient  to  remain  in  bed 
for  a  long  time  and  may  engender  a  large  number  of  complaints. 

Ktiologfy. — Weakness  of  the  myocardium  develops  most  fre- 
quently when  unusually  large  demands  are  made  upon  the  functional 
activity  of  the  heart-muscle,  and  with  which  the  heart  cannot  per- 
manently comply.  Among  such  causative  conditions  are  valvular 
lesions  of  the  heart,  chronic  diseases  of  the  respiratory  organs, 
constrictions  and  dilatations  (aneurysms)  of  the  aorta  or  the  pul- 
monary artery,  arteriosclerosis,  and  chronic  diseases  of  the  kidney. 

Bodily  over-exertion,  for  which  of  late  excessive  athletic  exer- 
cises (mountain-climbing,  bicycling,  rowing)  especially  atford 
abundant  opportunity,  and  the  ingestion  of  excessive  amounts  of 
fluids  (immoderate  use  of  beer)  may  also  give  rise  to  insufficiency 
of  the  heart-muscle. 

Diseases  of  the  myocardium  itself  (myocarditis,  fat  heart, 
tumors,  echinococci)  also  may  readily  be  associated  with  weakness 
of  the  heart-muscle,  because,  in  the  development  of  these  condi- 
tions, muscular  structure  of  the  heart,  therefore  functionally  capable 
tissue,  is  destroyed.     At  times  the  myocardium  is  involved  through 


22  CIRCULATORY  ORGANS 

extension  of  disease  from  adjacent  structures,  as,  for  instance, 
pericarditis,  obliteration  of  the  pericardium,  and  endocarditis. 

Among  the  toxic  varieties  of  myocardial  weakness  may  be  in- 
chided  those  that  arise  after  excessive  use  of  alcohol,  coffee, 
tobacco,  and  tea.  In  this  group  })erhaps  may  be  included  also 
some  infectious  diseases,  in  which  the  toxins  impair  the  integrity 
of  the  myocardium. 

At  times  general  loss  of  bodily  fluid  gives  rise  to  Meakncss  of 
the  myocardium,  as,  for  instance,  in  pulmonary  tuberculosis,  carci- 
noma, chronic  diarrhea,  and  suppuration. 

Occasionally  weakness  of  the  myocardium  is  dependent  upon 
alterations  in  the  blood,  and  it  occurs  in  connection  with  chlorosis, 
leukemia,  pseudoleukemia,  pernicious  anemia,  or  after  the  loss  of 
considerable  amounts  of  blood. 

From  the  nature  of  the.  causative  factors,  weakness  of  the 
myocardium  occurs  but  seldom  in  childhood.  Conversely,  a  natural 
predisposition  is  present  in  advanced  life — senile  iceahiess  of  the 
myoc(nrUiim. 

Anatomic  Alterations. — Weakness  of  the  heart-muscle  may 
cause  death  without  any  change  in  the  myocardium  whatever  being 
discoverable,  macroscopically  or  microscopically,  at  autopsy.  In 
the  majority  of  cases,  it  is  true,  the  myocardium  is  marked  at  least 
by  great  flaccidity  and  dilatation,  and  often  still  other  alterations 
in  it  will  be  found,  such  as  have  been  suggested  in  the  discussion 
of  the  etiology. 

The  anatomic  appearances  of  the  hypostatic  alterations  are  read- 
ily recognizable.  The  edema  of  the  skin  remains  demonstrable  also 
in  the  cadaver.  From  the  serous  cavities  (pleura,  pericardium, 
peritoneum)  large  amounts  of  clear  greenish-yellow  transudate  may 
often  be  evacuated.  The  cavities  of  the  heart,  especially  the  right 
ventricle  and  auricle,  are  greatly  distended  with  blood  and  blood- 
clots,  and  on  incision  of  the  ven^e  cavfe  such  an  abundance  of  blood 
escapes  as  to  suggest  the  possibility  of  an  increase  in  the  amount 
having  taken  place.  The  lungs  in  long-standing  cases  present  a 
brownish-red  color,  which,  as  microscopic  examination  proves,  is 
caused  by  an  abundant  accumulation  of  blood-pigment.  The  lungs 
appear  also  remarkably  dense,  in  consequence  of  increase  in  the 
interalveolar  connective  tissue,  and  the  condition  is  therefore 
spoken  of  as  brown  induration  of  the  htncjs.  The  mucous  membrane 
of  the  bronchi  is  conspicuous  for  its  marked  redness  and  swelling, 
and  is  covered  with  secretion.  The  spleen  is  usually  enlarged  in 
but  slight  degree,  but  by  reason  of  an  increase  in  its  connective 
tissue  it  generally  feels  remarkably  firm.  The  Mclneys  are  in- 
creased in  size,  and  usually  present  a  bluish-red,  almost  blackish- 
red,  color,  which  stands  out  sharply  upon  section,  especially  in  the 
medullary  portion.  The  condition  is  designated  cyanosis  of  the 
kidneys,  or,  when  the  connective  tissue  has  undergone  hyperplasia 


WEAKNESS  OF  THE  MYOCARDIUM  23 

after  long-continued  stasis  and  the  kidneys  have  acquired  a  firmer 
texture,  ci/anotic  induration  of  the  kidneys.  The  liver  also  has  in- 
creased in  size  and  it  contains  an  excessive  amount  of  blood.  On 
section,  in  consequence  of  marked  dilatation  and  distention  of  the 
central  veins  with  blood,  a  peculiar  appearance  is  noted,  suggest- 
ing the  form  of  an  oak-leaf  or  a  nutmeg,  whence  the  name  cyanotic 
nutmeg-liver.  If  hyperplasia  and  contraction  of  connective  tissue 
take  place,  the  liver  becomes  harder  and  nodular  upon  its  surface, 
and  the  condition  is  then  described  as  cyanotic  induration  of  the 
liver.  The  serosa  of  the  stomach  and  intestine  is  often  marked  by 
unusually  active  distention  of  the  finer  venous  blood-vessels,  and 
upon  the  mucous  membrane  swelling,  brownish-red  discoloration, 
and  active  secretion  of  mucus  are  striking.  The  'pancreas  also 
exhibits  venous  distention,  and  frequently  also  unusual  density  in 
consequence  of  connective-tissue  hyperplasia.  Marked  swelling 
and  venous  hyperemia  of  the  mucous  membrane  are  usually  pres- 
ent in  the  urinary  passages.  The  sinuses  of  the  dura  mater  are,  as 
a  rule,  distended  with  blood.  The  cerebrosjnnal  fluid  is  incre'dsed, 
and  upon  the  surface  of  tlie  l^rain  and  in  the  cortex  the  marked 
distention  of  the  veins  is  striking.  Xot  rarely  edema  of  the  brain 
and  slight  dilatation  of  the  cerebral  ventricles  have  developed. 

Prognosis. — The  prognosis  in  a  case  of  weakness  of  the 
myocardium  depends  upon  the  causes  and  the  severity  of  the  dis- 
order. Recovery  can  naturally  be  looked  for  only  when  the  causes 
are  removable;  but  even  then  death  may  occur  wlien  the  degree 
of  weakness  of  the  cardiac  muscle  is  so  great  that  the  heart  is  no 
longer  capable  of  recuperating. 

Treatment. — In  all  conditions  of  weakness  of  the  myocar- 
dium the  first  indication  is  the  removal  of  the  cause — causal  treat- 
ment. In  addition  the  following  symptomatic  treatment  should  be 
followed  :  The  patients  should  permanently  occupy  as  nearly  a 
horizontal  position  in  bed  as  possible,  and  confine  themselves  prin- 
cipally to  a  milk-diet.  Frequently  all  of  the  symptoms  will  dis- 
appear after  the  institution  of  these  measures  alone.  If  marked 
palpitation  of  the  heart  be  present,  an  ice-bag  should  be  placed 
continuously  over  the  heart,  and  finally  resort  is  had  to  cardiac 
tonics  or  stimulants.  Among  heart-tonics  digitalis-leaves  alone  are 
worthy  of  confidence,  while  their  substitutes  (tincture  of  stro- 
phanthus,  caifein  and  sodium  benzoate,  caifein  and  sodium  salicy- 
late, adonis  vernalis,  convallaria  raajalis,  spartein  sulphate,  and 
others)  are  quite  unreliable  agents.  We  prescribe  digitalis-leaves 
principally  in  the  form  of  powder,  and,  if  diuresis  be  deficient,  in 
combination  with  diuretin  (theobromin  and  sodium  salicylate) : 

R  Powdered  digitalis-leaves,  0.1  (1^  grains) ; 

Diuretin,  1.0  (15      "      ).— M. 

Make  10  such  starch-capsules. 
Dose :  1  every  two  hours. 


24  CIRCULATORY  ORGANS 

In  the  use  of  all  preparations  of  digitalis  certain  precautionary  meas- 
ures should  be  ol)served.  At  times  (oxlc  manifestations  (vomiting,  slowness 
of  pulse,  irregularity  of  pulse,  diplopia,  delirium)  apj)ear,  which  necessitate 
the  withholding  of  the  remedy.  The  cumulative  action  of  digitalis  must  also 
be  b(jrne  in  mind.  Some  persons  bear  digitalis  badly,  and  under  such  con- 
ditions enemata  of  infusion  of  digitalis  have  been  employed.  After  too  pro- 
tracted use  of  digitalis  the  heart  becomes  accustomed  to  the  remedy,  and  the 
activity  of  the  drug  is  lessened.  Patients  taking  digitalis  should  remain 
under  the  constant  observation  of  the  physician,  in  order  that  the  remedy  may 
be  withdrawn  at  the  proper  time. 

Stimulants  may  be  prescribed  with  advantage  when  transient 
conditions  of  myocardial  weakness  are  present,  or  when  the  myo- 
cardium has  undergone  such  a  degree  of  degeneration  that  digitalis 
is  incapable  of  exerting  its  effect.  A  maintained  influence  is  not  to 
be  expected  under  the  latter  conditions.  Among  agents  of  this  class 
employed  are  especially  camphor  internally,  or  camphorated  oil 
externally,  ether,  valerian-root,  and  ethereal  tincture  of  valerian. 

At  times  it  is  necessary  to  treat  specially  certain  threatening 
symptoms  ;  for  instance,  excessive  cutaneous  edema.  Diaphoresis 
by  means  of  pilocarpin  hydrochlorate  or  sweat-chambers  is  usually 
not  well  borne,  so  that  multiple  incisions  of  the  skin  or  puncture 
by  means  of  Southey  cannulas  are  preferably  to  be  recommended. 


DILATATION  OF  THE  HEART, 

Ktiology. — Dilatation  of  the  heart  may  involve  the  right  or 
the  left  side,  or  the  entire  organ.  At  times  it  is  acute,  at  other 
times  chronic  in  nature. 

The  conditions  favoring  dilatation  of  the  heart  are  always  pro- 
vided when  the  /Tswtance  of  the  myocardium  is  diminished  or  when 
the  blood-pressure  is  increased  in  excessive  degree.  Under  the  con- 
ditions first  mentioned  simple  dilatation  takes  place,  whereas  under 
the  second  to  the  dilatation  hypertrophy  of  the  heart-muscle  is, 
as  a  rule,  superadded  (so-called  eccentric  cardiac  hypertrophy). 

Diminished  resistance  of  the  heart-muscle  and  cardiac  dilatation 
are  observed  in  association  with  infectious  diseases,  loss  of  blood 
and  of  bodili/  fluids^  chlorosis,  pernicious  anemia,  leukemia,  pseudo- 
leukemia, and  allied  conditions.  Frequently  it  involves  only  the 
right  ventricle,  which  by  reason  of  the  greater  thinness  of  its 
muscular  wall  appears  of  itself  the  more  predisposed  to  dilatation. 
At  times  dilatation  of  the  heart  follows  poisoning  with  mineral 
acids,  alkalies,  phosphorus,  and  arsenic.  Diseases  of  the  myocar- 
dium itself  (cicatrices,  fat  heart)  also  give  rise  to  dilatation  of  the 
heart.  In  some  instances  congenital  deficiency  of  resistance  on  the 
part  of  the  myocardium  ajipears  to  bo  h(Mvditarv. 

Dilatation  (and  hypertrophy)  of  the  left  ventricle  in  consequence 
of  increased  blood-pressure  is  observed  especially  in  association  with 
insufficiency  of  the   aortic   valve,  stenosis   of  the    aortic   orifice, 


DILATATION  OF  THE  HEART 


25 


insufficiency  of  the  mitral  valve,  aneurysm  of  the  aorta,  constric- 
tion of  the  aorta,  arteriosclerosis,  and  contracted  kidney.  Dilata- 
tion (and  hypertrophy)  of  the  right  ventricle  develops  in  association 
with  insufficiency  of  the  mitral  valve,  mitral  stenosis,  insufficiency 
of  the  pulmonary  valve,  stenosis  of  the  pulmonary  orifice,  insuffi- 
ciency of  the  tricuspid  valve,  aneurysm  and  constriction  of  the 
pulmonary  artery,  pulmonary  emphysema,  chronic  bronchial 
catarrh,  chronic  pleurisy,  kyphoscoliosis,  and  the  like.  At  times 
to  dilatation  of  the  one  ventricle  is  gradually  superadded  a  similar 
state  of  the  other.     The  same  condition  arises  especially  in  con- 


FiG.  2.— Increased  area  of  cardiac  dulness  with  dilatation  of  the  right  ventricle  (mitral 
stenosis) ;  from  a  photograph  (personal  observation,  Zurich  clinic). 

junction  with  valvular  disease  of  the  heart  when  derangement  of 
compensation  occurs. 

Acute  dilatation  of  the  heart  in  consequence  of  increased  blood- 
pressure  is  at  times  induced  by  bodily  over-exertion  ;  for  instance, 
in  military  service,  mountain-climbing,  and  excessive  athletics. 

Dilatation  of  the  heart  is  most  frequently  encountered  in  men 
and  at  advanced  age,  which  is  readily  comprehensible  from  a  con- 
bideration  of  the  etiology. 

Symptoms  and  Diagnosis. — Dilatation  of  the  heart  may 
be  readily  recognized  from  tlie  change  in  the  area  of  cardiac  dulness. 
With   dilatation  of  the   ridit  ventricle   the  rioht  border  of  the 


2G 


CIRCULA  TOR  Y  OIKiA  XS 


(relatively)  largo  area  of  cardiac  percussion-dulness  extends 
beyond  the  right  sternal  margin  to  the  right  (Fig.  2),  while  with 
dilatation  of  the  left  ventricle  the  left  border  of  the  heart  extends 
beyond  the  left  niainniillary  line  to  the  left,  in  consequence  of 
which  the  area  of  percussion-dulness  at  the  same  time  acquires  an 
oval  outline  (Fig.  3).  In  the  presence  of  dilatation  of  the  left 
ventricle  the  apex-beat  of  the  heart  attains  unusual  extent,  being 
situated  outside  the  left  mammillary  line  and  usually  also  lower 
than  the  fifth  intercostal  space  on  the  left.  When  both  ventricles 
participate  in  the  dilatation  the  area  of  cardiac  dulness  exceeds  its 


Fig.  3.— Increased  area  of  cardiac  dulness  with  dilatation  of  the  left  ventricle  (insuflB- 
ciency  of  the  aortic  valve) ;  from  a  photograph  (personal  observation,  Zurich  clinic). 

natural  limits  both  to  the  left  and  to  the  right,  and  its  outline 
becomes  rather  rectangular  (Fig.  4). 

If  in  addition  to  dilatation  of  the  heart  hypertrophy  also  exists,  this, 
if  left-sided,  will  be  attended  with  a  heaving:  apex-beat,  accentuation  of  the 
aortic  second  sound,  and  a  hard  radial  pulse;  while  if  right-sided,  there 
will  be  accentuation  of  the  pulmonary  second  sound,  and  frequently  also 
unusually  active  systolic  vibration  over  the  sternum. 

Individuals  with  dilatation  of  the  heart  may  be  entirely  free 
from  discomfort.  This  is  especially  so  in  cases  in  which,  in 
addition  to  the  dilatation,  hypertrophy  of  the  heart-muscle  also 
exists,  because   both  conditions  tend    to  neutralize  any  possible 


DILATATION  OF  THE  HEART 


27 


increase  in  blood-pressure.  If  this  do  not  occur,  then  the  clinical 
picture  of  cardiac  insufficiency  makes  its  appearance,  with  all  of  its 
sequels  and  dangers,  and  this  takes  place  the  more  readily  when 
only  dilatation  of  the  heart  without  hypertrophy  is  present. 

Anatomic  Alterations. — Dilated  chambers  of  the  heart  are 
conspicuous  for  their  unusual  size.  If  the  left  ventricle  is  con- 
siderably dilated,  the  right  at  times  forms  only  a  sort  of  small 
appendage.  With  dilatation  of  both  ventricles  the  heart  often 
attains  such  considerable  proportions  that  it  has  been  designated 


Fig.  4.— Increased  area  of  cardiac  dulness  with  dilatation  of  both  sides  of  the  heart 
(insufficiency  of  the  mitral  valves) ;  from  a  photograph  (personal  observation,  Zurich 
clinic). 

an  ox-heart,  hucardia  (cor  bovinum,  enormitas  cordis).  In  a 
healthy  person  the  size  of  the  heart  should  not  exceed  that  of  the 
closed  fist.  Changes  in  the  shape  of  the  heart  also  take  place  in 
consequence  of  dilatation,  and  if  the  left  ventricle  be  involved 
this  assumes  an  oval  shape,  and  if  the  right  ventricle  this  assumes 
a  rectangular  shape ;  if  both  sides  are  involved,  the  appearance 
of  the  heart  has  been  compared  with  a  hunting-bag. 

Prognosis. — The  prognosis  in  case  of  dilatation  of  the  heart 
depends  upon  the  fact  whether  conditions  of  cardiac  weakness 
exist  whose  removal  is  possible. 


28  CIRCULATORY  ORGANS 

Treatment. — Treatment  of  dilatation  of  the  heart  is  indi- 
cated only  when  manifestations  of  myocardial  weakness  appear, 
and  is  then  to  be  conducted  npon  the  lines  laid  down  npon  pages 
23  and  24. 

HYPERTROPHY  OF  THE  HEART. 

Anatomic  Alterations. — Hypertrojihy  of  the  heart  may,  in 
the  same  way  as  dilatation,  involve  individual  portions  or  the 
entire  heart.  As  a  rule,  it  is  combined  with  dilatation  of  the 
heart — eccentric  hypertrophy  of  the  heart. 

Concerning  liypertrophy  of  the  heart  without  alteration  in  the  size  of 
its  cavities  {simple  hijperfrophy  of  tlie  heart),  and  even  concerning  such  hyper- 
trophy with  diminution  in  size  of  the  cavities  [concentric  hypertrophu  of  the 
heart),  little  of  a  certain  nature  is  known.  In  many  such  instances  the  con- 
dition is  probably  one  of  contraction  of  an  unaltered  heart-muscle  with  the 
occurrence  of  death. 

The  hypertrophied  segments  of  the  heart-muscle  are  conspicuous 
for  the  greater  thickness  of  the  wall,  and  usually  also  for  their 
greater  firmness.  At  the  same  time  the  weight  of  the  heart  (in  a 
healthy  individual  300  grams)  increases.  Further,  not  only  the 
walls  of  the  heart,  but  also  the  papillary  muscles,  frequently  take 
part  in  the  hypertrophy,  the  latter  becoming  converted  into  thick, 
plump  columns. 

HistoIogicaUy  it  can  be  shown  that  the  hypertrophy  of  the  heart-muscle 
is  brought  about  partly  through  increase  in  the  muscle-fibers  (hyperplasia) 
and  partly  through  increase  in  the  size  of  individual  muscle-fibers  (pure 
hypertrophy).  The  intermuscular  connective  tissue  may  also  be  increased 
in  amount. 

Htiology. — Only  increase  in  blood-pressure  is  with  certainty 
known  as  a  cause  for  hypertrophy  (and  dilatation)  of  the  heart,  and 
accordinglv  as  this  involves  the  aortic  system  or  the  distribution  of 
the  pulmonary  artery,  or  both,  will  the  left  or  the  right  ventricle 
or  the  entire  heart  be  involved  in  the  hypertrophy.  In  detail  all 
of  those  conditions  must  be  taken  into  consideration  that  have  been 
mentioned  on  pages  24  and  25  as  causes  for  dilatation  of  the  heart. 

Primary,  idiopathic,  or  essential  hypertropJiy  of  the  heart  has 
also  been  variously  spoken  of.  The  designation  is  inappropriate, 
and  should  l)e  re])laccd  by  fvnrtionaJ  JiypertropjJiy  of  the  heart- 
muscle,  for  idiopathic  hypertrophy  of  the  heart  occurs  in  persons 
who,  it  is  true,  exhibit  no  anatomic  alterations  in  their  circulatory 
organs,  but  who  have  been  compelled  to  perform  unusually  severe 
bodily  work,  or  have  made  unusually  large  demands  upon  the 
heart-muscle  through  the  ingestion  of  excessive  amounts  of  fluid 
(Munich  beor-heart).  Such  functional  hypertrojihy  of  the  heart 
occurs  especially  in  blacksmiths,  locksmiths,  seamen,  wine-growers, 
mountain-climbers,  and  soldiers. 

Whether  long-contimted  palpitation  of  the  heart  and  excessive  eatinf/  gWe 
rise  to  hypertrophy  appears  not  to  have  been  demonstrated  with  certainty. 


FAT  HEART  29 

With  regard  also  to  toxic  forms  of  cardiac  hypertrophy,  resulting  from  exces- 
sive use  of  coffee,  tea,  alcohol,  tobacco,  little  that  is  reliable  is  known. 

Symptoms  and  Diagnosis. — Hypertrophy  of  the  left  ven- 
tricle may  be  recognized  by  the  heaving  apex-beat,  the  accentuation 
of  the  aortic  second  sound,  and  the  hard  radial  pulse,  conditions  that 
are  readily  explained  by  the  increased  functional  activity  of  the 
left  ventricle.  If  the  thorax  be  sufficiently  yielding,  an  unusually 
marked  prominence  appears  in  the  cardiac  region,  so-called  pre- 
cordial bulging  (voussure)  takes  place. 

Hypertrophy  of  the  right  ventricle  is  attended  with  accentuation 
of  the  pulmonary  second  sound  (valvular),  for  the  greater  the  force 
with  which  during  the  systole  the  blood  is  driven  by  the  hyper- 
trophied  ventricle  into  the  pulmonary  artery,  the  greater  will  be 
the  violence  with  which  it  rebounds  against  the  pulmonary  valve 
and  causes  this  to  unfold  with  the  succeeding  diastole.  Less  regu- 
larly there  is  unusually  active  vibration  of  the  sternum,  beneath 
which  the  right  ventricle  lies. 

Hypertrophy  of  the  heart  is  a  desirable  outcome  in  the  pres- 
ence of  circulatory  disturbances,  and  through  its  agency  existing 
obstacles  can  be  overcome.  There  is  great  danger  when  the 
hypertrophied  heart  fails  in  strength,  for  then  there  develops  the 
clinical  picture  of  myocardial  weakness,  which  has  already  been 
described.  In  the  presence  o£  idiopathic,  or  functional,  hypertrophy 
also  there  is  danger  of  cardiac  weakness  ;  and  it  is  pathetic  to  wit- 
ness the  misery  of  a  robust,  well-developed  man,  with  an  immense 
heart,  suffering  from  and  eventually  succumbing  to  the  symptoms 
of  cardiac  weakness. 

Prognosis. — The  prognosis  in  cases  of  hypertrophy  of  the 
heart  depends  upon  the  functional  capahility  of  the  heart-muscle. 
Every  hypertrophied  heart  has  a  tendency  to  undergo  connective- 
tissue  and  fatty  degeneration,  and  to  lead  up  to  increasing  and 
incurable  cardiac  weakness.  At  times  such  conditions  occur  as 
transient  manifestations  when  extraordinary  demands  are  made 
upon  the  myocardium  in  consequence  of  physical  or  mental  excite- 
ment, alcoholic  and  venereal  excesses,  and  the  like.  Under  these 
conditions  the  prognosis  is  more  favorable,  providing  the  over- 
exertion of  the  heart  has  not  exceeded  a  certain  degree. 

Treatment. — Treatment  for  hypertrophy  of  the  heart  is  only 
indicated  when  signs  of  cardiac  weakness  appear,  and  is  then  car- 
ried out  in  the  manner  indicated  upon  pages  23  and  24. 


FAT  HEART  (COR  ADIPOSUM). 

Anatomic  Alterations. — By  fat  heart  in  the  clinical  sense 
is  understood  a  morbid  increase  in  the  fatty  tissue  that  is  present 
also  in  a  slight  degree  beneath  the  epicardium  of  a  normal  heart. 


30  CIRCULATORY  ORGANS 

This  tissue  may  in  the  presence  of  fat  heart  increase  until  it  forms 
a  fatty  capsule  more  than  one  centimeter  thick,  whicli  comjiletely 
envelops  the  heart-muscle.  Often  the  fatty  tissue  has  penetrated 
into  the  actual  muscular  substance,  in  which  by  pressure  it  has  in 
places  induced  atrophy.  The  heart  is  conspicuous  usually  for  its 
great  fllaccidity,  and  as  a  rule  it  is  increased  in  size. 

Ktiology. — Fat  heart  occurs  most  frequently  as  a  manifesta- 
tion of  plethora  or  of  over-eating  in  obese  individuals,  and  also  in 
those  who,  as  a  rule,  eat  innucderately  and  drink  alcohol  freely,  and 
take  little  physical  exercise  and  perform  little  \sork.  Of  more  sub- 
ordinate sitrnificance  is  the  anemic  or  cachectic  fat  heart,  which  is 
observed  in  connection  with  anemic  states  (chlorosis,  leukemia, 
pseudoleukemia,  progressive  pernicious  anemia,  following  loss  of 
blood  and  Avasting  discharges,  suppuration,  chronic  diarrhea).  Fat 
heart  is  usually  a  disease  of'  adult.s,  and  it  attacks  men  more  com- 
monlv  than  women. 

Symptoms  and  Diagnosis. — The  symptoms  of  fat  heart 
are  dependent  essentially  upon  the  fact  that  the  movements  of  the 
heart-muscle  are  interfered  with,  and  that  signs  of  cardiac  weakness 
gradually  appear  in  progressively  increasing  degree.  The  patients, 
as  a  rule,  complain  at  first  of  a  sense  of  constriction,  of  pressure, 
of  oppression,  in  the  precordium,  with  palpitation  of  the  heart 
and  dyspnea  on  slight  exertion,  and  finally  are  awakened  from 
sleep  and  harassed  by  attacks  of  dyspnea  at  night — so-called  car- 
diac asthma.  The  area  of  cardiac  dulness  is  noteworthy  by  reason 
of  its  intensity  and  its  increase  in  extent,  especially  toward  the 
right.  Xot  rarely  the  action  of  the  heart  is  irregular  and  acceler- 
ated. The  latter  symptom  is,  as  a  rule,  to  be  looked  upon  as  the 
first  sign  of  beginning  cardiac  weabiess,  upon  which,  sooner  or 
later,  manifestations  of  general  venous  stasis  are  prone  to  follow. 

At  times  fat  heart  is  attended  with  attacks  of  bradycardia, 
Cheyne-Stokes  breathing,  and  pseudo-apoplectic  attacks,  which  are 
attril)utable  to  an(!mia  of  the  medulla  oblongata  and  the  cerebral 
cortex.  Obviously,  the  functional  activity  of  the  heart  is  then 
impaired  in  so  marked  a  degree  that  it  is  no  longer  capable  of 
adequately  supplying  the  central  nervous  system  with  blood. 
This  triad  of  symptoms  is,  as  may  be  understood,  not  distinctive 
for  fat  heart,  appearing  also  when  the  central  nervous  system  is 
deprived  of  blood  from  other  causes. 

Most  patients  with  fat  heart  die  in  consequence  of  gradually/ 
increasing  cardiac  ireaJcness.  Less  commonly  death  results  from 
excessive  dilatation  of  the  heart  and  cardiac  ])aralysis.  Some 
patients  die  within  a  short  time  from   rupture  of  the  heart. 

The  diagnosis  of  fat  heart  is  by  no  means  easy,  and  is  really 
never  more  than  a  probability,  for  the  condition  will  be  suspected 
when  signs  of  disturbed  cardiac  activity  or  weakness  of  the  heart 
appear  in  an  obese  individual.     Specific  svmptoms  of  fat  heart  are 


INFLAMMATION  OF  THE  HEART-MUSCLE  31 

unknown,  and  even  in  an  obese  person  there  may  at  times  be  other 
causes  for  cardiac  Aveakness  than  fat  heart. 

Prognosis. — Fat  heart  demands  a  cautious,  though  usually 
a  serious,  prognosis,  for  obese  subjects  are  prone  to  be  contrite, 
though  but  rarely  reforming,  offenders.  The  further,  however,  the 
development  of  fat  heart  progresses  and  the  greater  the  amount 
of  heart-muscle  destroyed  by  pressure-atrophy,  the  more  likely 
is  incura1)le  myocardial  weakness  to  develop. 

Treatment. — If  in  a  case  of  fat  heart  conditions  of  cardiac 
weakness  have  appeared,  efforts  should  be  directed  to  their  removal 
according  to  the  principles  laid  down  on  page  23  and  24,  by  means 
of  heart-tonics,  especially  digitalis,  or  by  means  of  stimulants.  A 
r^'duction  in  the  amoiuit  of  cardiac  fat  can,  as  a  rule,  be  considered 
to  have  taken  place  only  when  the  heart  is  again  working  with 
sufficient  strength.  AA^hen  the  condition  arises  from  over-eating, 
food  and  drink  should  be  restricted,  and  the  patient  should  be 
enjoined  to  careful  and  progressively  increasing  indulgence  in  phys- 
ical exercise.  Besides,  the  use  of  potassium  iodid  may  be  recom- 
mended, which,  in  addition  to  its  fat-reducing  qualities,  possesses 
also  those  of  a  gentle  heart-tonic  : 

R  Solution  of  potassium 

iodid,  5  :  200  (75  grains  to  63  fluidounces). 

Dose  :  1  tablespoonful  thrice  daily  an  hour  after  eating. 

Courses  of  treatment  by  baths  at  Marienbad,  Homburg,  Kis- 
singen,  Tarasp,  etc.,  will  afford  only  temporary  relief  if  on  re- 
turning home  at  their  conclusion  the  patient  resumes  his  former 
habits. 

In  cases  of  anemic  and  cachectic  fat  heart  a  nutritious  diet  and 
preparations  of  iron  are  to  be  prescribed.  Among  health-resorts 
iron-baths  should  be  considered. 


INFLAMMATION   OF   THE   HEART-MUSCLE 
MYOCARDITIS). 

Anatomic  Alterations. — Among  the  various  forms  of  in- 
flammation of  the  myocardium  only  those  have  thus  far  received 
clinical  consideration  that  give  rise  to  the  development  of  con- 
nective-tissue foci  or  plates  in  the  heart-muscle,  so-called  myo- 
carditic  cicatrices.  Whether  these  are  from  the  outset  strictly 
inflammatory  in  nature  aj^pears  doubtful  from  recent  investiga- 
tions. Endarteritic  alterations  in  the  coronary  arteries  are  believed 
to  give  rise  to  their  development  most  frequently,  by  the  formation 
of  thrombi  at  the  narrowed  portions  of  the  arteries,  thus  cutting 
off  the  blood-supply  to  the  smaller  branches  of  the  coronary  arteries. 
The  related  anemic  areas  of  myocardium  undergo  necrotic  soften- 
ing— myomalacia    cordis ;    the    focus    of    softening    is    gradually 


32  CIRCULATORY  ORGANS 

absorbed,  and  in  its  place  there  appears  a  connective-tissue  cardiac 
cicatrix.  Tlie  number  and  size  of"  such  in(hirati(»ns  and  cicatrices 
are  very  variable,  and  it  is  especially  noteworthy  that  isolated,  small 
foci  of  connective-tissue  proliferation  have  given  rise  to  the  most 
distressing  symptoms,  Avliile  in  other  cases  most  extensive  con- 
nective-tissue deposits  have  been  unattended  with  symptoms. 
Often  the  heart-muscle  undergoes  hypertropliy. 

The  detection  of  myocarditlc  alterations  requires  the  making  of  horizontal 
sections  through  the  heart-muscle.  Sucli  changes  are  found  with  especial 
frequency  in  the  neighborhood  of  the  apex  of  the  heart. 

Ktiology. — As  the  later  years  of  life  (l)eyond  the  age  of  forty) 
are  frequently  attended  with  endarteritic  changes  in  the  coronary 
arteries,  it  will  be  understood  that  the  same  period  of  life  is  also 
characterized  by  a  tendency  to  the  formation  of  connective-tissue 
cardiac  cicatrices.  At  times,  however,  especially  through  the 
agency  of  certain  toxic  influences,  presenile  endarteritis  and  cica- 
trix-formation  in  the  heart-muscle  take  place  earlier  in  life,  and 
excessive  use  of  tea,  coifee,  alcohol,  and  tol^acco,  as  well  as  gout, 
diabetes,  contracted  kidney,  and  chronic  lead-poisoning,  are  not 
without  reason  mentioned  as  causes.  Closely  related  to  the  toxic 
varieties  of  myocarditis  are  the  infectious  varieties,  which  have 
been  observed  in  the  sequence  of  syphilis,  malaria,  articular  and 
muscular  rheumatism.  In  some  cases  myocarditic  cicatrices  have 
developed  in  the  sequence  of  previous  pericarditis  or  endocarditis 
through  extension  of  the  inflammatory  process  to  the  heart-muscle. 
Injuries  of  the  precordium  or  of  the  heart-muscle  itself  are  less 
common  causes  of  myocarditic  cicatrix-formation.  With  regard 
to  the  influence  of  expostire  to  cold  nothing  definite  is  known. 
That  myocarditis  is  most  common  in  men  of  advanced  years  should 
not  excite  surprise  in  view  of  the  etiology. 

Symptoms. — Myocarditic  cicatrices  give  rise  to  symptoms 
only  when  they  interfere  with  the  action  and  the  functional  capa- 
bility of  the  heart-muscle.  Palpitation,  irregularity  of  the  action  of 
the  heart,  and  a  sense  of  oppression  and  of  fear  are  usually  among  the 
earliest  symptoms,  and  are  followed  by  manifestations  of  progres- 
sively increasing  and  graduallv  insurmoimtable  cardiac  weakness 
and  general  stasis.  The  condition  may  persist  for  many  months 
and  years,  and  hence  has  also  been  designated  chronic  myocarditis. 
Overwhelming  stasis  is  the  most  common  cause  of  death.  At  times 
death  fakes  place  suddenly  in  consequence  of  a  variety  of  causative 
factors  ;  sometimes  it  may  result  from  over-distention  of  the  heart 
and  cardiac  paralysis.  In  the  presence  of  marked  narrowing  of 
the  coronary  arteries  in  consequence  of  endarteritis,  sudden  occlu- 
sion by  thrombi  or,  as  it  appears,  also  at  times  by  abnormal 
angulation  of  the  vessel,  will  under  some  conditions  cause  sudden 
death  in  consequence  of  anemia  of  the  heart-muscle.     Much  less 


TUMORS  OF  THE  MYOCARDIUM  33 

commonly  a  sudden  fatal  termination  occurs  from  rupture  of  the 
heart  or  cerebral  embolmn,  the  latter  originating  from  thrombi  in 
the  heart. 

Chronic  aneurysm  of  the  heart  may  be  mentioned  as  on  the  whole  an 
uncommon  sequel  of  chronic  myocarditis.  It  results  in  consequence  of 
saccular  dilatation  of  a  connective-tissue  cicatrix,  and  may  exceed  the  size 
of  the  heart.  The  condition  is  scarcely  susceptible  of  positive  diagnosis. 
An  area  of  cardiac  dulness  of  unusual  exient  and  irregular  shape,  anomalous 
pulsations  in  the  precordium,  and  mimmirs  in  the  same  situation  are  the 
principal,  but  not  unequivocal,  symj^toms.  Death  may  result  from  rupture- 
of  the  aneurysm,  or  from  embolism  arising  from  thrombi  in  the  aneurysm. 

Diagnosis. — Chronic  myocarditis  can  never  be  diagnosed 
with  certainty.  Only  existing  disturbances  of  cardiac  activity  and 
vigor  can  be  recognized  with  certainty ;  but  that  these  are  due  to 
cicatrix-formation  in  the  heart-muscle  can  under  the  most  favor- 
able conditions  be  correctly  interpreted  only  when  there  is  reason 
to  believe  that  all  other  causes  for  the  manifestations  named  can 
be  excluded. 

Prognosis. — The  prognosis  in  cases  of  chronic  myocarditis  is 
unfavorable,  for  no  remedy  is  capable  of  causing  disappearance  of 
the  cicatrices.  On  the  contrary,  there  is  danger  of  the  formation 
of  new  cicatrices,  with  steadily  increasing  cardiac  weakness. 

Treatment. — Prophylactic  treatment  is  applicable  to  the  toxic 
varieties  of  myocarditis,  and  should  be  directed  to  the  correction 
of  gout,  syphilis,  lead-poisoning,  and  the  use  of  alcohol,  tobacco, 
coffee,  and  tea.  Causative  treatment  is  indicated  when  arterio- 
"sclerosis  or  syphilis  is  present.  Under  both  of  these  conditions 
potassium  iodid  should  be  prescribed  (5.0  to  200 — 75  grains  to 
6-1-  fluidounces ;  a  tablespoonful  thrice  daily).  Naturally,  prophy- 
lactic and  causative  treatment  overlap,  as  a  rule,  without  sharp 
limitations.  Symptomatic  treatment  aims  principally  at  the  cor- 
rection of  existing  derangement  of  cardiac  action,  and  of  diminu- 
tion in  heart-strength,  and  can  be  carried  out  in  accordance  with 
the  suggestions  made  on  page  23  and  24. 

TUMORS   OF  THE   MYOCARDIUM   (NEW-GROWTHS 
OF  THE  HEART). 

Tumor-formations  in  the  heart-muscle  (carcinoma,  sarcoma,  myxoma, 
lipoma,  fibroma,  myoma)  occur  rarely,  and  can  never  be  diagnosed  with 
certainty.  Small  tumors  are  unattended  with  symptoms,  while  larger,  by  dis- 
placement of  the  heart-muscle,  give  rise  to  disturbed  action  of  the  heart 
and  to  weakness  of  the  heart-muscle  or  to  emboli,  when  fragments  of  the 
new-growth  are  broken  off  and  are  carried  with  the  blood-current  into 
peripheral  arteries.  At  times  symptoms  of  a  valvular  lesion  appear  from  the 
projection  of  the  tumor  toward  a  valve,  whose  activity  is  thus  interfered 
with.  Under  such  conditions  a  probable  diagnosis  may  be  possible  when 
tumors  are  demonstrable  in  peripheral  organs.  If  the  tumor  of  the  myo- 
cardium has  given  rise  to  an  increase  in  the  area  of  cardiac  dulness,  there 
is  danger  of  confusion  with  pericarditis. 
3 


34  CIRCULATORY   OIKIANS 

Treatment  is  futile,  and  should  be  confined  to  the  relief  of  individual 
symptoms.     The  j)rognosis  is  therefore  invariably  unfavorable. 

ECHINOCOCCUS  OF  THE  HEART. 

Ec'hinococcus  of  the  myocardium  is  an  extremely  rare  affection,  which 
experience  has  shown  to  involve  the  right  ventricle  most  frequently.  At 
times  the  cysts  rupture,  and  accordingly  as  the  discharge  takes  place  into 
the  right  or  the  left  ventricle  they  give  rise  to  emboli  in  the  distribution  of 
the  pulmonary  artery  or  the  aorta.  Sudden  occlusion  of  an  orifice  of  the 
heart  may  lead  to  sudden  death. 

Treatment  is  hopeless. 

DEXTROCARDIA. 

In  some  persons  the  heart  is  not  situated  on  the  left  but  on  the  right 
side  of  the  thorax,  so  that  the  cardiac  apex  likewise  is  directed  toward 
the  right  axillary  region  and  the  arch  of  the  aorta  winds  around  the  right 
bronchus.  The  condition  is  an  indiffereitf  congeniiul  one,  and  it  may  be 
present  in  the  most  healthy  and  most  robust  individual.  The  remaining 
organs  may  also  participate  in  the  displacement,  so  that  the  left  lung  has 
three  lobes,  the  liver  is  situated  beneath  the  left  half  of  the  diaphragm,  the 
spleen  beneath  the  right,  the  cardia  of  the  stomach  to  the  right  of  the  ver- 
tebral column,  the  pylorus  to  the  left,  etc.  Such  a  condition  i.s  known  as 
situs  viscerum  j^ervcrms  s.  inversus.  Care  must  be  taken  not  to  coni'ound 
dextrocardia  with  displacement  of  the  heart  in  consequence  of  left-sided 
pleurisi/  wiih  effusion.  It  may  also  happen  that  after  absori)tion  of  a  left- 
sided  pleural  effusion  has  taken  place  the  heart  is  bound  in  its  abnormal 
situation  by  adhesions ;  but  under  such  conditions  the  left  side  of  the  chest 
becomes  retracted.  Marked  contraction  of  the  right  lung  also  may  give 
rise  to  displacement  of  the  heart  in  the  right  half  of  the  chest ;  but  then  the 
right  side  of  the  thorax  becomes  retracted. 

CARDIORHEXIS  (RUPTURE  OF  THE  HEART). 

Etiology. — Rupture  of  the  heart,  apart  from  injiirij  of  the  heart,  ]>rob- 
ably  occurs  only  when  the  integrity  of  the  heart-muscle  has  been  impaired 
by  previous  disease.  Among  such  causative  conditions  are  especially  fat 
heart,  myocarditis,  tumor-formation  and  echinococcus  of  the  heart,  aneurysm 
and  abscess  of  the  heart-muscle,  and  softening  resulting  from  occlusion  of  the 
branches  of  the  coronary  arteries.  At  times  aneurysm  of  a  coronary  artery 
leads  to  attenuation  and  rupture  of  the  myocardium.  As  may  be  under- 
stood, rupture  will  readily  take  jilace  when  the  blood-pressure  has  undergone 
increase.  In  accordance  with  this  fact,  rupture  of  the  heart  has  not  rarely 
been  observed  in  connection  with  congenital  narrmring  of  the  isthmus  of  the 
aorta,  and  the  condition  has  arisen  frequently  after  psychic  and  physical 
exertion.  The  causes  named  explain  why  rupture  of  the  heart  is  most  com- 
mon in  men  of  advanced  years. 

Anatomic  Alterations. — When  rupture  of  the  heart  occurs  blood  is 
usually  poureil  out  in  large  amount  into  the  pericardial  sac,  so  that  this 
presents  the  appearance  of  an  intensely  distended  bladder  of  a  bluish-black 
color.  The  site  of  laceration  is  most  f'requent  in  the  left  ventricle,  close  to 
the  apex  of  the  heart,  and  the  opening  as  a  rule  is  occluded  by  blood-clots. 
The  tear  usually  takes  place  in  the  longitudinal  axis  of  the  fibers  of  the 
heart-muscle,  frequently  exhibits  a  sinuous  course  so  that  the  epicardial  and 
endocardial  oi)onings  are  not  in  apposition,  and  at  times  presents  ramifica- 
tions in  its  course. 


ACQUIRED    VALVULAR  DISEASE  OF  THE  HEART         35 

Symptoms  and  Diagnosis. — Eupture  of  the  heart  may  cause  sudden 
death.  At  other  times  the  victim  cries  out  that  something  has  ruptured  in  the 
precordiuin  ;  he  is  seized  with  an  indescribable  fear  and  a  premonition  of 
death,  presents  pale  and  distorted  features,  and  exhibits  the  signs  of  internal 
hemorrhage,  with  rapidly  increasing  enlargement  of  the  area  of  cardiac  dulness 
in  consequence  of  the  effusion  of  blood  into  the  pericardial  cavity.  Under 
such  conditions  also  death  usually  takes  place  within  a  short  time,  partly 
in  consequence  of  the  hemorrhage,  partly  in  consequence  of  interference 
with  the  action  of  the  heart,  at  times  also  as  the  result  of  shock. 

Prognosis  and  Treatment. — The  prognosis  is  unfavorable,  for  scarcely 
any  good  can  be  hoped  for  from  the  application  of  an  ice-bag  to  the  ^jre- 
cordium  and  the  administration  of  stimulants  and  styptics. 


II.    DISEASES   OF  THE   ENDOCARDIUM. 


ACQUIRED  VALVULAR  DISEASE  OF  THE  HEART. 

iEtiolog'y. — Acqtiired  valvular  disease  of  the  heart  is  one  of 
the  most  common  diseases  of  the  heart  and  diseases  in  general.  At 
times  the  condition  is  one  of  defect  in  closure  or  insujJicienGy  of  a 
valve,  at  other  times  one  of  constriction  or  stenosis  of  a  valvular 
orifice.  Often,  however,  both  conditions  are  present  together  in 
one  and  the  same  valvular  apparatus,  and  possibly  only  one  may 
preponderate.  If  several  valvular  apparatus  are  simultaneously 
diseased,  the  condition  is  designated  combined  valvular  disease  of 
the  heart. 

In  the  majority  of  cases  valvular  disease  of  the  heart  is  de- 
pendent upon  anatomic  alterations.  Much  less  commonly  the 
valvular  apparatus  is  itself  healthy,  but  is  insufficient  to  effect 
closure  on  account  of  morbid  dilatation  or  distention  of  the  val- 
vular orifice.  Such  a  condition  is  designated  relative  vcdvular 
insufficiency. 

Acquired  valvular  disease  of  the  heart  aft'ects  almost  exclu- 
sively the  valves  of  the  left  side,  especially  the  mitral,  Avliich  most 
frequently  is  the  seat  of  imperfect  closure.  Eight-sided  valvular 
disease  of  the  heart  is,  as  a  rule,  congenital.  An  exception  is  con- 
stituted by  relative  tricuspid  insufficiency,  which  develops  not 
rarely  in  the  sequence  of  mitral  disease,  and  Avith  especial  fre- 
(juency  after  mitral  stenosis. 

The  most  frequent  cause  of  acquired  valvular  disease  is  endo- 
carditis. This  usually  develops  after  infectious  diseases,  and  among 
these,  acute  articular  rheumatism  is  most  prominent.  Acute  artic- 
ular rheumatism  is  thus  the  most  common  cause  of  acquired  vcdvu- 
lar disease  of  the  heart.  In  childhood  scarlet  fever  is  an  important 
cause. 

At  times  valvular  disease  of  the  heart  does  not  develop  till  late 


3G  CIRCULATORY  ORGANS 

in  life,  wlien  tlio  aorta  and  tlic  aortic  valves,  less  commonly  the 
mitral  valve,  are  attacked  by  arteriosclerosis,  which  leads  to  thick- 
ening;, calcification,  and  contraction  of  the  valvular  tissue.  These 
alterations  are  frequently  looked  upon  as  constituting;  rhroiiic  endo- 
cardlfix. 

Oulv  rarelv  are  valvular  lesions  of  the  heart  induced  by  aneu- 
rysms of  valves,  neoplasms  upon  the  valves  or  in  their  proximity,  or 
by  laceration  of  valves.  Laceration  may  occur  also  in  healthy 
valves  in  consequence  of  excessive  physical  exertion,  and  has  been 
observed  in  all  the  valves  of  the  heart,  with  the  exception  of  the 
pulmonarv. 

Excessive  distention  of  the  heart  is  considered  the  cause  for 
relative  valvular  insufticiency.  As  has  been  mentioned,  relative 
tricuspid  insufiieiency  not  rarely  develops  in  association  with  mitral 
disease.  In  individuals  eng'ao:ed  in  heavy  physical  exertion  over- 
distention  of  the  left  ventricle  develops  at  times,  with  mitral 
insufficiency,  and  which  may  recede  Avith  care. 

Acquired  valvular  disease  of  the  heart  occurs  more  frequently 
in  adu/fs  than  in  children,  because  articular  rheumatism  occurs  but 
rarely  in  the  latter.  Clinical  statistics  are  almost  unanimous  in 
indicating  that  valvular  heart-disease  is  more  common  in  women 
than  in  men.  In  certain  regions  at  the  seaside,  and  in  damp  and 
foggy  places,  valvular  lesions  of  the  heart  are  encountered  with 
especial  frequency. 

Anatomic  Alterations. — The  anatomic  alterations  attending 
acquired  valvular  heart-disease  consist  mainly  in  deposits,  thicken- 
ings, even  calcification,  contraction,  adhesions,  or  detachment  of 
valvular  tissue.  Anatomic  alterations  are  wanting  only  in  cases 
of  relative  valvular  insufficiency.  In  addition  to  the  endocardium, 
the  heart-muscle  itself  is  almost  always  found  dilated  and  hy]X'r- 
trophied  in  certain  segments.  The  situation  of  the  parts  thus 
affected  depends  upon  the  nature  of  the  valvular  lesion.  As  most 
patients  with  valvular  heart-disease  die  in  consequence  of  weak- 
ness of  the  heart-muscle,  the  internal  viscera,  as  a  rule,  exhibit 
the  appearances  of  venous  stasis,  such  as  have  been  described  on 
page  18. 

It  is  by  no  means  always  easy  to  decide  at  autopsy  as  to  the  nature  of  a 
valvular  lesion  of  the  heart.  To  demonstrate  the  existence  of  insufficiency 
of  the  aortic  or  pulmonary  valve  a  strontr  stream  of  water  is  permitted  to 
fall  from  a  considerable  beisrht  into  tlie  trunk  of  the  arteries  named.  If  the 
valve  be  incompetent,  the  water  quickly  flows  into  the  ventricle,  while  if  it 
be  competent  the  water  will  be  supported.  In  the  presence  of  narrowinff 
of  the  aortic  or  pulmonary  orifice  sejitum-like  adhesions  of  the  valves  with 
one  another  or  cicatrix-like  contractions  of  the  orifice  are  frequently  encoun- 
tered. In  decidiuir  as  to  the  existence  of  incompetency  or  stenosis  of  the 
mitral  or  tricuspid  valve  or  orifice  the  knowledire  that  in  he.Tlthy  adults  the 
auriculoventricular  orifices  are  permeable  by  the  middle  and  index  fingers 
will  serve  as  a  suide. 


ACQUIRED   VALVULAR  DISEASE  OF  THE  HEART         37 

Symptoms. — For  the  recognition  of  acquired  valvular  disease 
of  the  heart  the  local  cardiac  afterations  furnish  the  indication. 
Frequently  general  disturbances  of  the  circulation  have  also  devel- 
ojjed,  and  these  are  most  frequently  manifested  as  general  venous 
stasis,  and  much  less  commonly  by  emboli.  We  shall  consider  these 
three  groups  of  symptoms  successively. 

Local  Cardiac  Manifestations  associated  with  Acquired  Valvular 
Disease  of  the  Heart. — 1.  Ao>iic  Insafficiency ;  Aortic  Iier/v.)rjita- 
fion. — The  principal  symptoms  of  aortic  valvular  insufficiency 
consist  in  an  aortic  diastolic  nmrmiir,  in  dilatation  and  hyper- 
trophy  of  the  left  ventricle,  and  in  an  accelerated,  full,  hard  radial 
pidse. 

If  the  aortic  valves  are  incompetent,  a  portion  of  the  aortic  blood,  during 
the  diastole  of  the  left  ventricle,  flows  back  into  this  chamber.  As  this 
cavity,  in  comparison  with  the  lumen  of  the  aorta,  represents  a  sudden  dila- 
tation of  the  blood-stream,  there  result  eddies  or  whirls,  which  give  rise 
acoustically  to  a  diastolic  murviur.  This  is  frequently  louder  over  the  middle 
of  the  sternum  than  over  the  area  of  auscultation  for  the  aorta  (right  second 
intercostal  space),  because  the  left  ventricle  is  in  closer  proximity  to  the 
middle  of  the  sternum.  The  murmur  may  also  be  transmitted  with  dimin- 
ishing intensity  to  the  other  valvular  areas,  to  the  carotid,  and  for  consider- 
able distances  upon  the  thorax.  Only  rarely  is  it  appreciable  at  some  distance 
from  the  patient,  and  more  frequently  it  is  palpable  as  a  diastolic  purring 
tremor  (fremissement  cataire). 

It  is  clear  that  if  the  left  ventricle  shall  receive  the  blood  regurgitated 
from  the  aorta  in  addition  to  that  sent  to  it  from  the  auricle,  dilatation  of  the 
ventricle  must  take  place,  and  this  adjusts  itself  to  the- degree  of  insuffi- 
ciency. This  is  recognized  by  the  appearance  of  the  apex-beat  outside  the 
left  inammillary  line  and  below  the  left  fifth  intercostal  space,  and  the  presence 
of  an  increased  area  of  cardiac  dulness  extending  beyond  the  left  mammil- 
lary  line  (page  26,  Fig.  3).  As,  however,  the  heart-muscle  will  be  compelled 
during  the  systole  to  send  more  blood  into  the  aorta  than  under  normal  con- 
ditions, and  thus  to  perform  a  greater  amount  of  work,  hyjiertroplni  of  the 
left  ventricle  will  be  a  further  necessary  sequel.  This  is  recognized  by  the 
heaving  apex-beat.  The  radial  pulse  exhibits  the  qualities  of  a  large,  hard, 
and  quick  pulse,  because  all  of  the  arteries  are  filled  with  an  abnormally 
large  amount  of  blood  under  unusually  high  pressure,  and  during  the  dias- 
tole of  the  heart  the  blood  flowing  back  against  the  semilunar  valves  is  not 


Fig.  5.— Sphygmographic  tracing  from  the  radial  artery  in  a  ease  of  aortic  valvular  insuffi- 
ciency (personal  observation,  Zurich  clinic). 

again  sent  on  into  the  arteries,  but  is  taken  up  by  the  left  ventricle.  A 
sphygmographic  tracing  exhibits  the  peculiarities  of  the  pulse  in  a  distinc- 
tive manner  (Fig.  5). 

In  addition  to  the  manifestations  described,  secondary  conditions  are 
present  as  a  rule  in  cases  of  aortic  valvular  insufiiciency,  which,  while  they 


38  CIIiCrLATOIlY   (JlKJANS 

complete  the  clinical  picture,  are  of  subordinate  importance  with  regard  to 
the  diagnosis.  Amon<r  these  may  be  mentioned  :  1.  Precordial  bulging  and 
nbnonnallii  active  and  luidilij  extended  cardiac  pnl-<ation.  These  result  from 
the  left-sided  hypertrophy  of  the  heart.  2.  A  systolic  heart-murmur,  pos- 
sibly the  result  of  irregular  contractions  of  the  myocardium.  This  may  be 
referred  to  simultaneous  stenosis  of  the  aortic  orifice  only  when  the  pulse 
is  not  rapid  but  retarded.  3.  Heaving  and  vibration  of  the  carotids  and  a 
carotid  systolic  murmur.  Excessive  distention  of  the  arteries  readily  leads 
to  irregular  vibrations  of  the  vessel-wall.  The  remaining  secondary  phe- 
nomena are  also  attributable  to  excessive  distention  of  the  arteries  with 
blood — such  as:  4.  Arterial  murmurs;  short  cardiac-systolic  murmurs  arc 
heard  also  in  the  smaller  arteries  ;  for  instance,  the  radial  or  the  palmar  arch. 
5.  Visible  pulsation  in  the  smaller  arteries  ;  for  instance,  the  temporal  and  the 
retinal.  6.  Visible  and  palpable  pulsations  in  various  organs  (uvula,  soft  pal- 
ate, penis,  and  enlarged  spleen).  7.  Visible  capillary  pulsation  (to  be  looked 
for  in  the  finger-nails  or  at  the  margin  of  an  area  of  skin  reddened  by 
rubbing).  8.  Traube's  double  murmur  in  the  femoral  artery.  On  careful  ap- 
plication of  the  stethoscope  a  systolic  and  a  diastolic  murmur  are  heard 
over  the  femoral  artery.  9.  Du'rosiez's  pressure-sign  in  the  femoral  artery. 
On  application  of  a  certain  amount  of  pressure  with  the  stethoscope  a  sys- 
tolic and  a  diastolic  murmur  can  be  heard  over  the  femoral  artery. 

Persons  with  aortic  valvular  insufficiency  bear  their  disease 
at  times  for  years  without  noteworthy  disturbance,  because  the 
left  ventricle  with  its  hypertrophied  musculature  is  capable  of 
neutralizing  the  disturbances  in  the  circulation  as  completely  as 
possible.  Annoying  palpitation  of  the  heart  is  frequently  the  first 
symptom.  Not  rarely  repeated  ephta.vis  takes  place.  To  this  oc- 
currence the  pallid  appearance  of  the  patients  has  been  attributed, 
but  this  is  also  observed  in  those  who  have  never  sutfered  from 
nose-bleed.  A  tendency  to  cerebral  hemorrhage  also  is  assigned  to 
individuals  with  aortic  valvular  insufficiency. 

2.  Aortic  Obdruction  ;  Aortic  t<tenoKi><. —  In  the  presence  of  con- 
striction of  the  aortic  orifice  there  first  occurs  a  systolic  murmur 
as  soon  as  the  blood,  during  tlie  systole  of  the  left  ventricle,  has 
passed  the  narrowed  aortic  opening  and  has  entered  the  wide  first 
part  of  the  aorta,  as  sudden  enlargement  of  the  current-bed  leads 
to  the  formation  of  blood-whirls.  The  murmur  is  often  marked 
by  es]iecial  intensity,  so  that  it  is  transmitted  from  the  right  sec- 
ond intercostal  space,  the  point  of  auscultation  for  the  aorta,  to  the 
remaining  valves  and  still  fartlier,  and  it  is  not  rarely  palpable  as 
a  systolic  purring  tremor. 

An  obstruction  to  the  blood-stream  at  the  beginning  of  the  aorta  must 
necessarily  lead  to  hypertrophy  and  dilatation  of  the  left  ventricle,  in  order 
that  the  obstruction  may  be  overcome.  The  dilatation  will,  however,  be  but 
slight  in  comparison  with  that  which  develops  in  association  with  aortic 
valvular  insufficiency,  because  regurgitation  of  blood  into  the  ventricle  does 
not  take  i)lace.  The  condition  of  tlio  radial  |)ulse  is  important,  exhibiting 
on  palpation  and  in  a  sjihygmographic  tracing  the  characters  of  an  infre- 
quent, small,  and  retarded  pulse  (page  39,  Fig.  6). 

Smallness  and  retardation  of  the  pulse  may  be  ex])lained  by  the  slow 
entrance  of  the  blood  into  the  aorta,  while  the  slow  pulse  may  be  referred 
to  insufficient  distention  of  the  coronarv  arteries  of  the  heart. 


ACQUIRED    VALVULAR  DISEASE  OF  THE  HEART         39 

Persons  with  aortic  stenosis  usually  exhibit  a  pallid  appearance 
in  consequence  of  imperfect  filling  of  the  arterial  system  with 
blood,  and  they  not  rarely  suffer  from  attacks  of  syncope  when 
cerebral  anemia  is  excessive. 

3.  3Iitral  Lvmffi^ciency ;  llitral  Regurgitation. — Incompetency 
of  the  mitral  valve  gives  rise  to  a  systolic  murmur,  which  is  usu- 


FiG.  6. — Sphygmographic  tracing  of  a  radial  pulse  from  a  case  of  stenosis  of  the  aortic 
orifice  (personal  observation,  Zurich  clinic). 

ally  loudest  at  the  apex  of  the  heart,  less  commonly  over  the 
pulmonary  orifice,  and  to  dilatation  and  hypertrophy  of  both 
ventricles. 

When  tlie  mitral  valve  is  incompetent  the  blood  during  the  systole  of 
the  left  ventricle  is  propelled  not  only  into  the  aorta,  but  in  part  back  again 
into  the  left  auricle.  In  consequence,  the  left  auricle  is  compelled  to  receive 
an  unusually  large  amount  of  blood  ;  namely,  that  from  the  pulmonary  veins 
plus  that  regurgitated  from  the  ventricle.  This  is  possible  only  if  dilatation 
of  the  left  auricle  takes  place,  although  this  first  physical  consequence  of 
mitral  valvular  insufficiency  is  without  clinical  significance.  As  the  left 
auricle,  in  comparison  with  the  contracting  left  ventricle,  represents  a  sud- 
den expansion  of  the  blood-stream,  and,  besides,  as  two  currents  of  blood 
are  poured  into  the  auricle  at  the  same  time,  blood-whirls  must  be  gener- 
ated, which  are  appreciable  acoustically  as  a  systolic  murmur,  and  if  of 
sufficient  intensity  are  also  palpable  as  a  sijstolic  pur  ring  tremor.  The  blood 
passing  from  the  pulmonary  veins  into  the  left  auricle  finds  this  cavity  par- 
tially filled  with  blood  regurgitated  from  the  left  ventricle,  and  stasis  must 
therefore  result.  This  blood-stasis  extends  from  the  area  of  the  pulmonary 
veins  to  that  of  the  pulmonary  capillaries  and  the  pulmonary  artery,  and 
finally  to  the  right  ventricle.  In  order  that  the  latter  may  overcome  the 
stasis  dilatation  and  hypertrophy  of  the  right  ventricle  must  take  place.  This 
dilatation  is  manifested  by  enlargement  of  the  area  of  cardiac  dulness  beyond 
the  right  sternal  margin,  while  the  hypertrophy  leads  to  accentuation  of  the 
pulmonary  second  sound,  and  not  rarely  also  to  unusually  active  vibration  of 
the  sternum. 

In  the  presence  of  mitral  valvular  insufficiency  increased  functional 
demands  are  made  not  only  upon  the  right,  but  also  upon  the  left  ventricle, 
for  with  each  systole  a  greater  amount  of  blood  (normal  amount  of  auric- 
ular blood  plus  the  regurgitated  blood)  must  be  sent  not  only  into  the  tube 
of  exit  (aorta),  but  into  two  cavities  (aorta  and  left  auricle).  In  order  to 
acconnnodate  the  greater  amount  of  blood  dilatation  of  the  left  ventricle  will 
develop,  and  in  order  to  propel  the  blood  hypertrophy  of  the  left  ventricle  will 
be  superadded.  In  accordance  with  the  dilatation  of  the  ventricles  the 
area  of  cardiac  dulness  becomes  enlarged  both  to  the  right  and  to  the  left 
(page  27,  Fig.  4).  The  apex-beat  of  the  heart  is  then  generally  extensive, 
being  displaced  outward  beyond  the  left  mammillary  line  and  often  also 
downward,  and  heaving,  the  last  in  consequence  of  hypertrophy  of  the  left 
side  of  the  heart. 


40  CIRCULATORY  ORGANS 

4,  3fifrnl  Ohsfnirfiou  ;  Jflfrfil  <S7r»o.s-/.s. — A  presystoltG  murmur 
and  (!il(t(<ifion  and  Jii/pcrtrojjJii/  of  tlie  right  ventricle  arc  the'  prin- 
ci})al  local  symptoni.s  of  mitral  stenosis. 

Tlie  presystolic  murmur  is  generated  by  the  formation  of  whirls  in  the 
blood  passing  during  the  diastole  of  the  left  ventricle  froin  the  left  auricl» 
through  the  constricted  mitral  orifice  into  the  large  left  ventricle.  P>e- 
quently  a  presi/stolic  purring  tremor  is  also  palpable. 

Not  rarely  t\\e  presystolic  vmrmur  appearit  loudest  at  tite  fjeginni/ig  and  at 
the  close  of  the  diastole,  for  at  the  beginning  the  left  ventricle  is  still  empty, 
and  the  formation  of  the  blood-whirls  therefore  very  active;  and  toward 
the  end  of  the  diastole  the  left  auricle  undergoes  contraction,  and  thus 
gives  rise  to  renewed  activity  in  the  formation  of  Ijlood-whirls. 

iJilatation  and  hyjjertrojjhji  of  the  right  venfricle  are  a  natural  consequence 
of  the  obstruction  that  the  blood  of  the  left  auricle  encounters  at  the  con- 
stricted mitral  orifice  and  of  the  resulting  stasi-^,  which  extends  through  the 
pulmonary  veins,  the  jjulmonary  capillaries,  and  the  pulmonary  arteries  to 
the  right  ventricle.  ' 

At  times  the  diastolic  sound  over  the  aorta  and  the  pulmonary  artery  appears 
duplicated.  This  is  explained  by  the  fact  that  the  pressure  in  tlie  aorta  and 
the  pulmonary  artery  has  undergone  such  pronounced  alteration  in  conse- 
quence of  the  mitral  stenosis  that  the  semilunar  valves  of  the  aorta  close 
earlier  than  those  of  the  pulmonary  artery. 

The  systolic  sound  at  the  apex  of  the  heart  frequently  is  unusually  clear 
and  loud,  perhaps  in  consequence  of  the  fact  that  the  difference  in  tension 
of  the  mitral  valvular  leaflets  during  the  systole  and  diastole  of  the  left 
ventricle  in  cases  of  mitral  stenosis  is  unusually  great. 

5.  Tricuspid  luHvfficiency  ;  Tricuspid  Ber/urr/itnfion. — In  addi- 
tion to  a  systolic  munnur  over  the  tricuspid  valve  and  dilatation  and 
hypertrophy  of  the  right  ventncle,  a  positive  venous  pulse  especially 
is  indicative  of  incompetency  of  the  tricnspid  valve,  and  from  the 
presence  of  which  the  valvular  lesion  can  often  be  at  once  sus- 
pected. 

In  cases  of  incompetency  of  the  tricuspid  valve  a  ]>ortion  of  the  ventric- 
ular blood  will  flow  back  into  the  right  auricle  during  the  systole  of  the 
right  ventricle.  As,  however,  the  right  auricle  n\ust  also  receive  the  blood 
from  both  veiuie  cavts,  it  must  undergo  increase  in  capacity.  Dilatation  of 
the  right  auricle,  therefore,  takes  place,  but  this  plays  clinically  oidy  a  subor- 
dinate role.  As  soon  as  the  blood,  during  the  systole,  is  thrown  back  from 
the  right  ventricle  into  the  right  auricle  blood-whirls  ensue  in  the  latter, 
and  are  ai)preciable  acoustically  as  a  systolic  murmur,  for  the  still  empty 
auricle,  as  compared  with  the  contracting  right  ventricle,  represents  ji  sudden 
expansion  of  the  blood-stream,  and,  in  addition,  it  is  distended  by  two  cur- 
rents of  blood  (regurgitated  blood  from  the  ventricle  and  blood  from  the 
vena?  cavse).  Dilatation  of  the  right  ventricle  \\'\\\,  therefore,  develop,  because 
the  right  ventricle,  during  the  systole,  must  receive,  in  addition  to  the 
normal  auricular  blood,  also  that  forced  back  into  the  right  auricle  during 
the  ]ireceding  systole.  As,  however,  the  right  ventricle,  during  the  systole, 
must  again  jn-opel  this  large  amount  of  l)lood.  and  must  pump  into  two 
orifices  of  exit  (pulmonary  artery  and  right  ventricle),  it  must  perform  a 
greater  amount  of  work,  and  accordingly  hypjertrnj>hy  of  the  right  ventricle 
takes  place. 

The  blood  forced  back  from  the  right  ventricle  into  the  right  auricle 
during  the  systole,  presupposing  sufficient  power  on  the  part  of  the  heart- 
muscle,  is  driven  into  the  superior  and  inferior  vena?  cavse,  and  thus  gives 
rise  to  a  positive  venous  pulse.     In  the  distribution  of  the  superior  vena  cava 


ACQUIRED    VALVULAR  DISEASE  OF  THE  HEART         41 

a  positive  venous  pulse  first  appears  in  the  neck,  and  earliest  in  the  external 
jugular  vein.  The  blood  surging  upward  encounters  resistance  within  the 
internal  jugular  vein  at  the  point  where  the  semilunar  valves  of  the  bulb 
of  this  vein  are  situated,  and  in  consequence,  between  the  inferior  points  of 
origin  of  the  sternomastoid  muscle  just  above  the  sternoclavicular  articu- 
lation, a  rhythmic  cardiac-systolic  vibration  is  visible,  the  bulbar  pulse. 
This  can  also  be  felt  as  a  short  blow ;  and  on  auscultation  a  short  sound  can 
be  heard,  the  bulbar  valvular  sound.  Soon,  however,  the  orifice  of  the  bulb 
becomes  so  greatly  distended  that  its  valves  are  no  longer  capable  of  effecting 
closure,  and  relative  insufficiency  of  the  bulbar  valve  takes  place.  The  blood 
regurgitated  from  the  right  ventricle  into  the  superior  vena  cava  can  now  be 
forced  into  the  internal  jugular  vein  itself,  and  there  results  a  venous  pulse 
in  this  vessel.  Above  the  bulb  of  the  jugular  vein  a  cardiac-systolic  bulbar 
murmur  is  then  not  rarely  audible,  and  at  times  a  systolic  bulbar  thrill  is 
also  palpable.  If,  however,  the  jugular  vein  is  greatly  distended  by  the 
ujjward-surging  blood-stream,  a  cardiac-systolic  venous  murmur  results. 

A  positive  venous  pulse  may  also  be  visible  in  the  smaller  branches  of 
the  superior  vena  cava,  especially  in  the  large  veins  of  the  arm  and  the  face. 

An  hepatic  venous  pulse  results  when  the  blood  from  the  right  ventricle 
is  forced  into  the  right  auricle  and  the  inferior  vena  cava  with  every  systole, 
and  rhythmically  fills  the  distribution  of  the  hepatic  veins  with  blood. 
The  pulsation  can  be  seen  and  still  more  frequently  felt  with  the  hand 
when  both  hands  are  placed  upon  the  anterior  and  jDOsterior  aspects  or  upon 
the  right  and  left  sides  of  the  liver. 

In  some  cases  the  blood- wave  finds  its  way  into  the  femoral  artery, 
where  it  gives  rise  (just  below  Poupart's  ligament),  in  the  same  manner  as 
in  the  internal  jugular  vein,  to  a  femoral  bulbar  pulse,  a  venous  valvular  mur- 
mur, relative  valvular  insufficiency,  a  femoral  venous  pulse,  and  even  a  saphenous 
pulse,  to  bulbar  murmurs  and  a  femoral  venous  murmur. 

Often  a  venous  pulse  appears  only  temporarily,  disappearing  when  the 
vigor  of  the  heart  has  grown  so  slight  that  regurgitation  of  a  visible  and 
palpable  ])ulse-wave  does  not  occur;  and  it  will  not  appear  in  the  internal 
jugular  vein  and  the  femoral  vein  as  long  as  the  bulbar  valves  close,  or  with 
diminishing  stasis  become  again  competent. 

The  following  condition  may  be  mistaken  for  the  cervical  venous  pulse: 
1.  Respiratory  movements  in  the  veins  of  the  neck.  These  cease  when  respira- 
tion is  suspended ;  2.  Pulsatile  movements  imparted  by  the  carotid  artery. 
Pressure  upon  the  artery  mterrupts  the  pulsation  in  the  carotid  and  at  the 
same  time  also  that  in  the  veins  of  the  neck;  3.  Negative  venous  pulse. 
During  the  systole  of  the  right  auricle,  and  the  diastole  of  the  right  ven- 
tricle, the  blood  stagnates  in  the  superior  vena  cava  and  gives  rise  to  a 
rhythmic  pronounced  distention  of  the  cervical  veins  ;  but  in  the  first  place 
this  distention  does  not  occur,  like  that  of  the  positive  venous  pulse,  at  the 
time  of  the  systole,  but  during  the  diastole  of  the  heart,  so  that  a  negative 
venous  and  a  carotid  pulse  are  not  synchronous  but  alternating ;  and  besides, 
when  the  vessel  is  compressed  the  negative  venous  pulse  necessarily  dis- 
appears below  the  point  of  compression,  while  the  positive  venous  pulse 
is  uninfluenced  by  this  manipulation,  and  frequently  becomes  even  more 
distinct. 

Hepatic  venous  pulse  might  be  confounded  with  pulsation  imparted  to 
the  liver  from  the  abdominal  aorta,  but  under  such  circumstances  there 
would  be  only  simple  elevation  and  depression  of  the  organ,  while  in  the 
presence  of  a  positive  hepatic  venous  pulse  a  general  cardiac-systolic  enlarge- 
ment of  the  liver  takes  place. 

6.  Tricuspid  Obstruction;  Tricuspid  Stenosis. — Tricuspid  steno- 
sis is  an  uncommonly  rare  valvular  lesion  of  the  heart  which  gives 
rise  to  a  presystolic  murmur  over  the  tricuspid  orifice  and  to  dilata- 


42  CIRCULATORY  ORfLiXS 

Hon  and  hypertrophy  of  the  rir/ht  auricle.     The  latter  leads  to 
increase  in  the  area  of  cardiac  dulness  toward  the  right. 

7.  Pulmonary  Ins-ajfictency  ;  Pulmonary  Per/nrf/ifafion. — Insuf- 
ficiency of  the  pulmonary  valve  is  recognized  by  a  diastolic  mur- 
mur over  the  pulmonary  orifice  (left  second  intercostal  space  close 
to  the  left  sternal  border)  and  by  dilatation  and  hypertrophy  of  the 
rifjht  ventricle.  The  development  of  these  alterations  is  exactly 
tlie  same  as  that  of  the  corresponding  manifestations  attending 
insufficiency  of  the  aortic  valve,  but  referable  to  the  right  instead 
of  the  left  heart.  This  form  of  valvular  lesion  also  is  rarely 
observed. 

8.  Pulmonary  Obstruction  ;  Pulmonary  Stenosis. — Constriction 
of  the  pulmonary  orifice  is  usually  a  congenital  and  but  seldom  an 
acquired  valrular  lesion  of  the  heart.  A  systolic  murmur  over  the 
pulmonary  orifice,  frequently  a  systolic  purring  tremor,  and  dilata- 
tion and  hypjertropjhy  of  the  right  ventricle  are  the  distinctive  mani- 
festations. These  arise  in  the  same  manner  as  the  corresponding 
alterations  associated  with  aortic  stenosis,  but  with  reference  to  the 
circulation  tlirough  the  pulmonary  artery  and  the  right  ventricle. 

General  Venous  Stasis  attending  Valvular  Lesions  of  the  Heart, 
Weakness  of  the  Heart-muscle,  or  Derangement  of  Compensation. — 
The  circulatory  disturbances  to  which  a  valvuhir  lesion  of  the 
heart  gives  rise  can  only  be  neutralized  to  a  certain  degree  by 
dilatation  and  hypertrophy  of  certain  portions  of  tlie  heart,  which 
thus  compensate  for  the  valvular  lesion.  As  soon  as  the  vigor  of 
the  heart-muscle  becomes  impaired  the  condition  arises  tliat  is 
designated  derangement  of  compensation,  and  there  develops  the 
clinical  picture  of  general  venous  stasis,  as  described  on  page  18. 
Such  a  derangement  of  compensation  may  be  transitory  and  the 
result  of  disturbance  of  innervation  or  of  over-distention  of  the 
heart.  It  occurs  also  in  the  sequence  of  mental  and  physical  ex- 
ertion, of  alcoholic  and  venereal  excess,  injudicious  use  of  tea, 
coffee,  tobacco,  and  the  like.  Many  persons  suffer  repeatedly  from 
attacks  of  derangement  of  compensation,  which  again  subside  under 
proper  ]>recautions.  Xevertheless,  in  spite  of  all  care,  derange- 
ment of  compensation  will  become  more  and  more  marked,  because 
an  hypertrophied  lieart-muscle  manifests  a  tendency  to  fatty  and 
connective-tissue  degeneration,  with  increasing  cardiac  weakness. 
Such  conditions  are  usually  incurable  and  progressive,  and  eventu- 
ally cause  death. 

Embolic  Alterations  attending  Valvular  Lesions  of  the  Heart. — 
In  addition  to  derangements  of  compensation,  patients  suffering 
from  valvular  lesions  of  the  heart  are  especially  exposed  to  danger 
from  emboli.  These  result  from  the  detachment  of  deposits  upon 
the  valves,  which  enter  the  blood-current  and  are  with  it  carried 
to  the  arteries  of  remote  organs,  in  tiie  smaller  branches  of  which 
thev  finallv  lodo;e  as  emboli.     Emboli   occur  most  frequently  in 


ACQUIRED   VALVULAR  DISEASE  OF  THE  HEART         43 

the  arteries  of  the  spleen,  the  kidney,  the  extremities,  and  the 
brain,  wliile  they  are  much  less  common  in  the  hepatic  arteries, 
the  mesenteric  arteries,  and  the  retinal  artery.  The  sudden  onset 
of  the  symptoms  and  the  usually  sudden  pain  are  among  the  dis- 
tinctive features  of  embolism. 

Embolism  of  the  splenic  artery  is  characterized  by  the  appearance  of 
sudden  pain  in  the  splenic  region,  acute  enlargement  of  the  spleen,  tender- 
ness of  the  organ  on  pressure,  and  at  times  by  audible  and  palpable  peri- 
splenitic  friction-murmurs.  With  the  occurrence  of  the  embolism  vomiting, 
chill,  and  fever  may  be  present.  Embolism  of  the  renal  artery  may  likewise 
be  attended  with  vomiting,  chill,  fever,  and  sudden  pain  in  the  renal  region. 
In  addition  the  urine  contains  blood — hematuria.  Embolism  of  the  hepatic 
artery  is  very  rare,  and  gives  rise  to  marked  jaundice  and  rapid  diminution 
in  the  size  of  the  liver,  thus  to  the  clinical  picture  of  acute  yellow  atrophy 
of  the  liver.  Embolism  of  the  mesenteric  artery  causes  sudden  pain  in  the 
abdomen,  peritonitis,  and  bloody  stools.  Embolism  of  the  artery  of  an  ex- 
tremity is  attended  with  loss  of  pulsation  and  with  coldness  of  the  affected 
member  below  the  point  of  occlusion,  and  if  an  adequate  collateral  circula- 
tion fails  to  be  established  gangrene  sets  in.  Embolism  of  the  cerebral  arteries 
is  m(jst  common  in  the  distribution  of  the  left  carotid,  which  represents  the 
continuation  of  the  aorta,  and  thus  leads  to  occlusion  of  the  left  Sylvian 
artery.  The  patients  are  usually  rendered  unconscious  with  the  occurrence 
of  the  embolism,  and  suffer  a  stroke  or  attack  of  apoplexy.  When  con- 
sciousness returns  right-sided  palsy  will  be  observed,  hemiplegia  dextra,  and 
frequently  also  aphasia.  Embolism  of  the  retinal  artery  causes  sudden  blind- 
ness. On  examination  with  the  ophthalmoscope  the  macula  lutea  presents 
the  appearance  of  a  cherry-red  spot  in  the  anemic  retina. 

Diagnosis. — The  diagnosis  of  a  valvular  lesion  of  the  heart 
can  be  made  only  when  endocardial  murmurs  are  demonstrable  on 
auscultation.  At  times  the  blood-pressure  is  so  low  as  not  to  gen- 
erate audible  blood-whirls,  and  when  a  valvular  lesion  is  suspected 
an  attempt  may  be  made  to  increase  artificially  the  blood-pressure 
by  rapid  walking  or  by  movement  of  the  body  to  and  fro.  It  is 
also  advisable  to  auscultate  the  heart  in  both  the  upright  and  the 
horizontal  position  of  the  body,  at  the  end  of  inspiration  and  of 
expiration,  and  to  note  the  presence  of  possible  murmurs. 

While  diastolic  murmurs  scarcely  occur  except  in  association 
with  valvular  lesions,  systolic  murmurs  may  also  be  present  in 
association  with  febrile  and  anemic  states  as  accidental  murmurs. 
A  diagnosis  of  valvular  lesion  of  the  heart  may  therefore  be  made 
from  the  presence  of  such  murmurs  only  when  some  portions  of 
the  heart  can  be  shown  to  be  dilated  and  hypertrophied.  Dilata- 
tion alone  is  not  sufficient,  as  it  may  be  the  result  also  of  the  fever 
or  the  anemia.  Besides,  it  should  be  borne  in  mind  that  accidental 
murmurs  almost  never  give  rise  to  purring  tremor. 

For  myself  an  additional  important  adjunct  in  differential  diagnosis, 
which,  as  a  rule,  is  not  present  in  association  with  valvular  lesions,  is  the 
fact  that  the  pulse  is  least  frequent  in  the  recumbent  posture,  more  frequent 
in  the  sitting  posture,  and  most  frequent  in  the  standing  posture. 

For  the  correct  localization  of  heart-murmurs  the  rule  should 


44  CIRVULATORY  ORGANS 

be  rio^idly  observed  that  iminmirs  are  generated  at  those  valves 
over  wliich  they  are  heard  with  greatest  intensity.  As  has  been 
mentioned,  exeeptions  oeeiir  at  times  in  tiie  ease  of  insntficieney 
of"  the  aortie  and  the  mitral  valve.  If  there  be  doubt  whether  a 
murmur  is  aortic  or  pulmonary,  it  should  be  noted  whether  it  per- 
sists as  the  stethoscope  is  moved  toward  the  right  or  the  left.  In 
the  first  instance  it  is  generated  in  the  aorta.  If,  h(jwever,  it  dis- 
appears as  the  stethoscope  is  moved  toward  the  right,  while  it  per- 
sists with  the  movement  of  the  instrument  toward  the  left,  it  is 
])ulmonary  in  origin.  The  same  principles  apply  to  the  differentia- 
tion between  mitral  and  tricuspid  mtn'murs. 

Combined  valvular  lesions  of  the  heart  may  be  readily  recognized 
Avhen  tlic  one  lesion  gives  rise  to  a  systolic  and  the  other  to  a  dias- 
tolic murmur.  If,  however,  murmurs  occur  at  the  same  time,  these 
may  be  transmitted  from  one  valve  to  another,  and  the  differenti- 
ation would  depend  upon  the' fact  whether  the  murmurs  exhibited 
different  acoustic  characters  at  different  situations,  and  whether 
the  dilatation  and  the  hypertrophic  alterations  in  the  heart-muscle 
indicated  a  combined  valvular  lesion.  In  order  to  diagnose  an 
associated  aortic  stenosis  together  with  the  existence  of  aortic 
insufficiency  from  the  presence  of  a  systolic  murmur,  the  fact 
should  be  taken  into  consideration,  as  has  been  mentioned, 
whether  the  radial  pulse  is  retarded  or  not.  The  combination 
of  a  valvular  lesion  with  tricuspid  insufficiency  is  indicated  by  a 
positive  venous  pulse. 

The  anatomic  alterations  are,  as  a  rule,  not  susceptible  of 
diagnosis.  .Vs  the  clinieal  diagnosis  relates  only  to  the  functional 
disturbance  of  the  diseased  valve,  it  not  rarely  occurs  that  at  the 
autopsy  the  impression  is  created  of  an  existing  stenosis  nither  than 
of  the  diagnosed  insufficiency,  and  vice  versa. 

Prognosis. — Valvular  lesions  of  the  heart  are  insusceptible 
of  cure  l)y  the  administration  of  drugs,  and  tiie  prognosis  is  corre- 
spomlingiy  unfavorable.  In  rare  instances  spontaneous  recovery 
takes  place,  perhaps  because  of  the  gradual  disappearance  of 
deposits  upon  valves,  or  the  stretching  of  healthy  valves,  or  the 
retraction  of  dilated  orifices.  With  the  necessary  rest  of  body  and 
mind,  and  an  (ij,j)i()pri((fe  mode  of  /if e,yi.\\yu\av  lesions  of  the  heart 
may  be  survived  for  decades.  \\]  frhri/r  disetisrs  and  in  women  pver/- 
nfdiri/  readily  iniluce  cardiac  weakness  and  derangeuKMit  of  com- 
pensation. Valvular  lesions  of  the  heart  acquired  in  childhood  are 
attended  with  the  danger  of  derangement  of  compensation  at  the 
period  of  puberty.  Sufferers  from  valvular  heart-disease  are  but 
rarely  attacked  by  puhnondrii  fiihercidosis.^     An  exception  is  con- 

'  Tliis  statement  would  seem  to  require  iiioditication.  While  piilmonarv 
tuberculosis  may  be  less  common  in  association  with  valvular  disease  of  the  heart 
than  with  other  conditions,  it  can  scarcely  be  said  to  be  rare.  The  subject  woidd 
appear  to  be  worthy  of  further  investigation. — A.  A.  E. 


CONGENITAL  HEART-DISEASE  45 

stitiited  by  pnlinonarv  stenosis,  in  connection  ^vith  which  pulmonarv 
tubercidosis  occurs  frequently,  probably  in  consequence  of  im- 
paired nutrition  and  diminished  resistance  on  the  part  of  the 
lungs. 

Treatment. — There  is  no  remedy  Jor  valndnr  disease  of  the 
heart.  Of  late  saline  baths  have  been  much  employed,  especially 
those  of  Xauheim  ;  but  recovery,  even  under  these  conditions, 
occurs  only  exceptionally.  The  greatest  importance  in  the  treat- 
ment of  a  patient  suti'ering  from  valvular  disease  should  be  placed 
upon  a  quiet  physical  and  psychic  mode  of  life,  and  upon  a  light  and 
yet  nutritious  diet,  especially  a  judicious  milk-diet.  Medicaments 
should  be  prescribed  only  when  threatening  symptoms  ariise.  Most 
frequently  weakness  of  the  heart-muscle  and  derangements  of 
compensation  must  be  corrected,  in  accordance  with  the  rules  laid 
down  upon  page  23  and  24.    Digitalis  is  the  most  trustworthy  agent. 

CONGENITAL   HEART-DISEASE. 

Anatomic  Alterations. — Congenital  lesions  of  the  heart  are 
rare  forms  of  cardiac  disease.  The  condition  most  commonly  found 
is  congenital  stenosis  of  the  pulmonary  orifice.  Lesions  of  the  tri- 
cuspid, but  es23ecially  those  of  the  valves  of  the  left  side  of  the 
heart,  are  unusually  rare  occurrences.  Congenital  heart-lesions, 
however,  not  only  involve  the  valves  and  orifices  of  the  heart,  but 
also  at  times  give  rise  to  patency  of  the  foramen  ovale,  to  deficiency 
of  the  interauricular  and  the  interventricular  septum,  to  patency, 
absence,  or  aneurysmal  dilatation  of  the  duct  of  Eotal,  or  to  transpo- 
sition of  the  great  vessels,  the  aorta  arising  from  the  right  and  the 
pulmonary  artery  from  the  left  ventricle.  Frequently  several  con-- 
r/enital  lesions  of  the  heart  exist  in  association  ;  especially  with  pul- 
monary stenosis  the  foramen  ovale  and  the  duct  of  Botal  not  rarely 
remain  patulous,  so  that  the  l)lood  may  pass  from  the  right  into  the 
left  auricle  and  from  the  aorta  through  the  duct  of  Botal  into  the 
pulmonary  artery.  Naturally,  such  persistence  of  fetal  circulatory 
paths  is  unnecessar}'  even  when  the  pulmonary  orifice  is  not  merely 
constricted,  l)ut  entirely  closed. 

!^tiology. — Xothing  definite  is  knoM'u  as  to  the  causes  of  con- 
genital lesions  of  the  heart.  Among  some  that  have  been  men- 
tioned are  psychic  disturbances  and  injuries  during  pregnancy,  articular 
rheumatism  during  pregnancy,  syphilis,  and  consanguinity  in  the 
parents.  At  times  several  children  in  the  same  family  have  been 
born  with  congenital  lesions  of  the  heart.  Experience  has  shown 
that  hoys  suffer  more  commonly  than  girls.  Most  frequently  the 
condition  appears  to  be  a  defect  in  the  development  of  the  heart, 
to  Avhieh  this  organ,  by  reason  of  the  numerous  changes  in  shape 
through  which  it  passes  during  fetal  life,  appears  to  be  particularly 
exposed.    At  times  other  developmental  defects  have  been  observed 


46 


CIRCULATORY  ORGANS 


in  association  with  congenital  lesions  of  the  heart ;  for  instance, 
liarelij),  club-foot,  congenital  deaf-mntisin.  In  otlier  instances 
the  condition  may  be  the  consequence  of  fetal  endocarditis,  to  which 
the  right  heart  is  the  more  predisposed  during  uterine  life,  because 
it  receives  the  blood  arteriaiized  in  the  placenta,  and  to  a  certain 
degree  assumes  the  functions  later  taken  up  by  the  left  ventricle. 
Symptoms  and  Diagnosis. — Congenital  lesions  of  the  heart 
may  hv  unattended  with  symptoms — latent  concjenital  heiirt-disease. 

Among  the  a})])reeiab]e  man- 
ifestations are  congenital  cya- 
nosis and  local  cardiac  altera- 
tions. 

Congenital  cyanosis  is  char- 
acterized by  a  bluish-red,  at 
times  almost  blackish-blue, 
discoloration  of  the  skin  and 
mucous  membranes,  so  that 
the  condition  has  been  named 
morbus  coeruleus.  Obviously 
the  appearance  is  the  result 
of  delicient  oxidation  of  the 
blood  ;  possibly,  however,  the 
unusually  large  number  of 
red  blood-corpuscles  and  the 
large  amount  of  hemoglobin 
also  may  contribute  to  the 
result.  Not  rarely  children 
with  congenital  lesions  of  the 
heart  are  apparently  dead  at  birth.  If  resuscitation  take  place, 
the  peculiar  color  of  the  skin  is  often  conspicuous  from  the  begin- 
ning. In  other  instances  the  cyanosis  appears  only  on  crying, 
on  exposure  to  cold,  and  after  physical  exertion.  The  lips  and 
the  nose  appear  swollen  and  the  eyeballs  frequently  project  mark- 
edly forward.  The  terminal  phalanges  of  the  fingers  and  toes 
exhibit  peculiar  alterations,  being  expanded  like  drum-sticks — 
drum-stick  fingers  (Fig.  7).  At  the  same  time  there  is  a  tendency 
to  frost-bite  and  inflammation  of  the  terminal  phalanges.  The 
skin  feels  cool,  and  the  patients  suffer  readily  from  cold  and  prefer 
the  neighborhood  of  the  stove.  They  avoid  play  with  those  of 
their  own  age,  as  they  suffer  from  palpitation  of  the  heart  and 
shortness  of  breath,  and  they  appear  quiet,  retiring,  introspective, 
and  mentally  unresponsive. 

The  local  cardiac  alferafions  depend  upon  the  nature  of  the 
congenital  heart-lesion.  In  the  presence  of  congenital  ])ulmonary 
stenosis  a  systolic  murmur  is  audible  over  the  pulmonary  orifice, 
and  dilatation  and  hypertrophy  of  the  right  ventricle  take  place. 
Patulousness  of  the  foramen  ovale  and  deficiencv  of  the  inter- 


Fio.  7.— Drura-stick  fingers  of  congenital  pul- 
monary stenosis ;  from  a  photograph  (personal 
observation,  Zurich  clinic). 


INFLAMMATION  OF  THE  ENDOCARDIUM  47 

auricular  or  the  interventricular  septum  can  never  be  recognized 
with  certainty.  At  times  extended  presystolic  or  systolic  mur- 
murs are  audible  over  the  lieart.  Changes  in  the  duct  of  Botal 
have  hitherto  been  insusceptible  of  diagnosis. 

The  principal  dangers  from  congenital  lesions  of  the  heart  con- 
sist in  weakness  of  the  myocardium  and  stasis,  and  in  the  case  of 
congenital  pulmonary  stenosis  in  pulmonary  tubei^Gulosis.  Most 
subjects  of  congenital  heart-disease  do  not  survive  the  fourteenth 
year  of  life. 

Prognosis. — The  prognosis  is  unfavorable  in  accordance  with 
what  has  been  said.     Recovery  is  out  of  the  question. 

Treatment. — The  treatment  is  the  same  as  that  of  acquired 
lesions  of  the  heart. 

INFLAMMATION  OF  THE  ENDOCARDIUM 
(ENDOCARDITIS). 

Several  forms  of  endocarditis  have  been  distinguished,  and 
they  have  been  designated  ulcerative,  verrucose,  and  contracting. 
Ulcerative  and  verrucose  endocarditis  are  due  to  the  activity  of 
bacteria,  and  the  same  microorganisms  may  give  rise  to  the  one  or 
the  other  variety.  Transitional  and  mixed  forms  are  also  observed 
both  anatomically  and  clinically.  Contracting  endocarditis  leads 
to  thickening,  contracition,  and  frequently  also  to  calcification  of 
the  endocardium,  and  is  often  the  sequel  of  a  preexisting  verru- 
cose endocarditis.  In  other  instances  it  develops  independently 
as  a  manifestation  of  senility,  and  often  in  association  with  arterio- 
sclerosis. Excessive  physical  activity,  excessive  use  of  alcohol, 
chronic  disease  of  the  kidneys,  gout,  and  diabetes  also  are  causes. 
In  contradistinction  from  ulcerative  and  verrucose  endocarditis, 
the  contracting  variety  pursues  a  chronic  course,  so  that  it  has  been 
designated  also  chronic  endocarditis.  It  constitutes  the  most  com- 
mon anatomic  cause  for  valvular  ledons  of  the  heart,  and  it  exhibits 
a  great  tendency  to  become  again  acute,  when  it  is  designated 
recurrent  contracting  endocarditis. 

ULCERATIVE  ENDOCARDITIS. 

Ktiology. — Ulcerative  endocarditis  is  most  commonly  the 
sequel  of  a  preexisting  wound-infection.  Then,  it  is  not  rare  in 
the  sequence  of  infectious  diseases.  At  times  a  causative  factor  is 
not  elicitable,  and  under  such  conditions  the  designation  crypto- 
genetic  endocarditis  has  been  employed.  In  this  category  prob- 
ably belong  also  the  instances  in  which  exposure  to  cold,  excessive 
physical  activity,  and  psychic  disturbances  have  been  assigned  as 
etiologic  factors. 

Among  wonnd-infections  it  should  especially  be  mentioned  that  ulcer- 
ative endocarditis  not  rarely  develops  in  association  with  puerperal  fever. 


48  CIRCULATOR V  OnCANS 

P'urther,  the  smallest  wound  is  sufficient  to  afford  entrance  for  bacteria  into 
the  blood  and  to  the  endocardium.  In  this  connection,  not  only  external, 
but  also  internal,  wounds  must  be  taken  into  consideration  ;  for  instance, 
those  of  the  mucous  membrane  of  the  digestive  apparatus.  Among  iii/ec- 
tious  (liseasen  acute  articular  rheuuiatisni  especially  is  a  fiequent  cause  of 
ulcerative  endocarditis.  Among  the  acute  exanthemata,  xcarlet  fever  is 
of  especial  importance.  Of  late  ulcerative  endocarditis  has  been  observed 
a  number  of  times  in  the  sequence  of  gonorrhea.  In  cases  of  cniptof/euetic 
ulcerative  endocfirditis  the  tonsils  may  often  be  the  portal  of  entry  for  the 
bacteria. 

Experience  has  shown  that  tcomen  are  more  commonUj  attacked 
by  ulcerative  endocarditis  than  men.  The  disease  is  rare  in  chihl- 
hood.  It  occurs  most  commonly  between  the  twentieth  and  the 
fortieth  year  of  life. 

Anatomic  Alterations. — The  first  changes  in  ulcerative  en- 
docarditis consist  in  a  deposit  ujion  the  endocardium  that  is  com- 
posed principally  of  masses  of  bacteria.  If  this  be  detached,  a  loss 
of  tissue,  usually  sharply  circumscribed,  becomes  apparent.  Fre- 
quently fibrinous  masses  are  deposited  at  these  points  (endocarditic 
vegetations),  which,  as  a  rule,  are  less  abundant  than  in  cases  of 
vcrrucose  endocarditis.  The  lesion  of  the  endocardium  may  lead 
to  perforation  and  destruction  of  the  valve-structure  ;  or  it  may 
give  rise  to  an  acute  aneurysm  of  the  valve  if  only  one  layer  of 
the  valve  is  destroyed.  The  ulcerative  process  may  also  extend 
to  the  myocardium  and  give  rise  to  an  acute  myocardial  ulcer. 
Should  saccular  dilatation  of  the  myocardium  take  place  at  such 
a  point,  an  acute  aneurysm  of  the  heart  will  result. 

Ulcerative  endocarditis  most  frocpiently  attacks  the  valves  of 
the  heart,  especially  those  of  the  left  side,  and  the  alterations 
involve  the  lines  of  closure  of  the  valves.  It  attacks  the  tendinous 
cords,  the  papillary  muscles,  and  the  mural  endocardium  much  less 
commonly.  At  times  several  valves  are  involved  sinuiltancously, 
both  ujion  the  right  and  u])on  the  left  side. 

The  most  frequent  exciting  agent  of  ulcerative  endocarditis  is 
the  staphylococcus  pyogenes  aureus  and  the  streptococcus  pyogenes, 
although  a  number  of  other  bacteria  have  been  isolated  from  the 
endocarditic  inflammatory  areas,  at  times  specific  bacteria,  such  as 
gono(!occi  and  typhoid-bacilli. 

Ulcerative  endocarditis  is  characterized  by  a  great  tendency  to 
the  development  of  bacterial  embolism.  Small  masses  of  bacteria 
become  detached  from  the  inflamed  endocardium,  and  are  carried 
through  the  arterial  blood-current  into  the  most  diverse  organs, 
where  they  become  lodged  in  the  smaller  blood-vessels,  forming  at 
first  a  grayish  or  grayish-white  center,  surrounded  by  a  zone  of 
hyperemia.  Soon,  however,  inflammation  and  sup})uration  are 
superadded.  Frequently  the  individual  organs  contain  numerous 
emboli  and  fi)ci  of  suppuration,  and  only  few  viscera  escape  this 
complication. 


INFLAMMATION  OF  THE  ENDOCARDIUM  49 

Symptoms  and  Diagnosis. — Ulcerative  endocarditis  is  only 
susceptible  of  diagnosis  when  in  addition  to  a  septic  general  condi- 
tion signs  of  a  valvular  lesion  of  the  heart  are  also  present.  As  long 
as  the  cardiac  valve  remains  functionally  competent  only  the  general 
septicemia  can  be  recognized.  This  at  times  pursues  a  course  sug- 
gestive of  typhoid  fever  (continued  fever,  dry,  coated  tongue,  dis- 
tended abdomen,  roseola,  splenic  enlargement,  diarrhea) ;  at  other 
times,  chills  followed  by  elevation  of  temperature,  lasting  for 
several  hours,  and  recurring  with  a  certain  degree  of  regularity, 
and  splenic  enlargement,  raise  a  suspicion  of  intermittent  fever  ;  or 
iinally  suppurative  inflammation  occurs  in  one  or  more  organs, 
which,  together  with  possible  chills,  are  due  to  bacterial  emboli. 

In  doubtful  cases  it  is  especially  important  to  look  for  emholie 
alterations  in  the  skin,  the  mucous  membranes  (of  the  mouth,  the 
conjunctiva),  and  the  retina.  In  these  structures  hemorrhages  may 
be  frequently  observed,  in  which  the  bacterial  plug  may  be  recog- 
nized as  a  white  center.  Further,  roseolous,  scarlatiniforra,  and 
pustular  eruptions  also  occur  upon  the  skin. 

In  a  case  of  doubtful  diagnosis  a  physician  trained  in  bacteriologic 
methods  would  examine  the  stools,  the  urine,  and  the  blood  of  the  rose-spots 
for  the  presence  of  typhoid-bacilli,  or  the  blood  for  malarial  plasmodia.  In 
cases  of  ulcerative  endocarditis,  on  the  other  hand,  it  is  not  uncommonly 
possible  to  obtain  pyogenic  cocci  from  the  blood. 

Such  valvular  alterations  as  may  be  present  will  manifest  them- 
selves by  endocardial  murmurs,  which  are  mostly  systolic  and  less 
commonly  diastolic  in  occurrence.  To  these  dilatation  of  the 
heart  may  be  superadded.  The  disease  usually  pursues  too  rapid 
a  course  for  hypertrophy  to  develop. 

Death  may  take  place  within  three  days.  At  times,  however, 
the  disease  is  protracted  for  months.  Recovery  is  scarcely  to  be 
hoped  for.  Life  is  terminated  either  with  progressive  failure  of 
strength,  or  in  consequence  of  secondary  suppuration,  or  of  embo- 
lism of  an  important  cerebral  vessel. 

Prognosis. — The  prognosis  is  almost  unexceptionably  un- 
favorable. 

Treatment. — A  nutritious  liquid  diet  should  be  prescribed 
(milk,  bouillon  with  egg,  coffee,  tea,  wine),  an  ice-bag  is  kept  ap- 
plied continuously  to  the  precordium,  and  digitalis  is  prescribed  to 
strengthen  and  slow  the  action  of  the  heart ;  the  last  may  be  com- 
bined with  benzoic  acid  and  camphor  when  asthma  is  present. 
Mercuric  chlorid  and  quinin  have  also  been  employed  for  the  pur- 
pose of  destroying  the  bacteria  upon  the  endocardium. 

VERRUCOSE  ENDOCARDITIS. 

iJ^tiology. — Verrucose  endocarditis  is  caused  by  the  same  bac- 
teria as  the  ulcerative  variety.  Why  in  the  one  instance  the  disease 
assumes  the  verrucose  type  and  in  the  other  the  ulcerative  type  is 

4 


50  CIRCULATORY  ORGANS 

not  definitely  known.  Infectious  diseases  of  all  kinds  are  the  most 
common  cause  of  the  disorder.  Ainonir  the  most  conspicuous  of 
these  are  acute  articular  rheumatism  and  in  childhood  ncarlet  fever. 
Debilitating  diseases  (carcinoma,  })ulmoiiarv  tuberculosis,  chronic 
nephritis)  also  favor  infection  and  iuHannnatiou  of  the  endtjcar- 
dium.  Exposure  to  cold  and  injury  further  act  as  etiologic  factors, 
although  these  must  be  consitlered  only  as  contributory  causes  favor- 
ing infection  of  the  endocardium.  Experience  has  shown  that  verru- 
cose  endocarditis  occurs  more  commonly  in  men  than  in  women,  and 
especially  hefu-ren  the  fu-rntleth  and  the  fortieth  year  of  life. 

Anatomic  Alterations. — The  characteristic  alterations  of 
verrueose  endocarditis  consist  in  throml)otic  deposits,  endocarditic 
vegetations,  upon  the  iuHamed  areas  of  the  endocardium,  which 
not  rarely  in  appearance  resemble  an  extensive  cock's  comb,  cauli- 
flower, or  condyloma.  As  a  rule,  the  endocarditis  involves  the 
valves,  the  vegetations  being  situated  at  the  lines  of  closure.  The 
mitral  valve  is  attacked  with  especial  frequency.  Inflammation 
of  the  pulmonary  and  tricuspid  valves  is  uncommon.  As  may  be 
understood,  the  vegetations  are  capable  of  interfering  with  the 
function  of  the  affected  valves  and  inducing  the  manifestations  of 
a  valvular  lesion  of  the  heart.  In  the  further  course  of  the  morbid 
process  organization  of  the  vegetations  takes  place.  Thickenings 
occur,  even  calcification  of  the  valve,  with  contraction  and  adhe- 
sions, and  the  valvular  lesion  becomes  a  permanent  one. 

Bacteria  can  frequently  be  demonstrated  in  the  vegetations  only  by  cul- 
ture-methods. When  the  vegetations  have  existed  for  some  time  bacteria 
are  no  longer  present. 

A  frequent  complication  of  verrueose  endocarditis  is  constituted 
by  emboli,  which  result  from  the  disintegration  of  endocarditic 
vegetations.  These  do  not,  as  a  rule,  excite  inflammation  in  the 
affected  organ,  because  they  do  not  contain  bacteria  or  contain 
them  in  too  small  number,  but  they  give  rise  to  the  manifesta- 
tions of  an  emljolic  infarct. 

Symptoms  and  Diagnosis. — Verrueose  endocarditis  can  be 
recognized  only  ihmi  the  development,  in  the  course  of  days  or 
weeks,  of  the  symptoms  of  a  valvular  lesion  of  the  heart,  most  fre- 
quently those  of  mitral  insufficiency.  In  the  condition  last  named 
a  systolic  murmur  first  apjunirs.  Gradually  dilatation  of  the  right 
side  of  the  heart  is  superadded,  and  finally  the  jMilmonarv  second 
sound  becomes  acc(Mitnated  an<l  indicates  hy})ortrophv  of  the  right 
heart.  At  times  elevation  of  temperature,  palpitation  of  the  heart, 
a  sense  of  constriction,  and  irregularity  of  the  pulse  appear  ;  but  fre- 
quently the  disease  develops  quite  insidiously,  and  is  recognized 
only  by  thorough  and  repeated  examination  of  the  heart.  If 
emholisn}  develops,  the  symptoms  described  on  pages  42  and  43 
make  their  appearance. 


THROMBOSIS  OF  THE  HEART  51 

Prognosis. — l^  vermcose  endocarditis  has  given  rise  to  a 
valvidar  lesion  of  the  heart,  this  usually  persists  for  the  remainder 
of  life,  and  is  attended  with  all  of  the  dangers  that  have  already 
been  mentioned,  especially  derangements  of  compensation  and 
eml)oli~ni. 

Treatment. — The  treatment  is  the  same  as  that  for  ulcerative 
endocarditis  (page  49). 

THROMBOSIS  OF  THE  HEART, 

Etiology. — Fibrinous  deposits  upon  the  endocardium  take  place  wlien 
the  endothelium  is  diseased,  and  in  consequence  has  lost  its  capability  of 
maintaining  the  fluidity  of  the  blood  in  the  cavities  of  the  heart.  This 
occurs  in  conjunction  with  inflammations  of  the  endocardium  and  with 
marantic  states,  so  that  a  distinction  can  be  made  between  inflaininaionj  and 
marantic  tkromboiiis  of  the  heart.  Slowing  of  the  blood-current  favors  the 
formation  of  thrombi.  Whether  a  morbid  tendency  of  the  blood  to  the 
deposition  of  fibrin  occurs  or  not  is  doubtful. 

Anatomic  Alterations. — Cardiac  thrombi  form,  besides,  upon  inflamed 
valves,  with  especial  frequency  near  the  apex  of  the  heart,  in  the  ventricles, 
and  in  the  auricular  appendages.  They  vary  in  size  and  form.  At  times 
the  fibrinous  masses  are  lodged  between  the  fleshy  columns,  occupying  their 
interstices  more  or  less  completely:  at  other  times  the  thrombi  are  sus- 
pended from  slender  pedicles  in  the  cavity  of  the  heart — so-called  true  cardiac 
polypi.  An  uncommon  variety  of  cardiac  thrombus  is  the  globular  thrombus, 
a  freely  movable  thrombus  of  roundish  shape  in  the  auricle,  which  may 
cause  immediate  death  by  sudden  closure  of  a  venous  orifice.  At  times 
thrombi  undergo  softening  in  their  interior,  and  then  they  may  contain  a 
chocolate-brown  or  pus-like  fluid.  Cardiac  thrombi  are  differentiated  from 
post-mortem  fibrinous  deposits  by  the  fact  that  they  are  tougher,  rather 
brownish-red  or  grayish-red,  and  adherent  to  the  endocardium. 

Symptoms  and  Diagnosis. — The  symptoms  of  cardiac  thrombosis  are 
of  such  diverse  nature  that  even  under  the  most  favorable  conditions  the 
disorder  can  only  be  suspected  with  a  certain  degree  of  probability.  At 
times  morbid  manifestations  are  entirely  wanting — latent  cardiac  thrombosis. 
In  other  instances  signs  of  vjeahiess  of  the  heart  become  more  and  mor« 
prominent.  In  still  other  instances  fragments  of  thrombus  become  broken 
off  and  find  their  way  as  emboli  into  the  distribution  of  the  pulmonary 
artery  or  of  the  aorta,  respectively.  Sudden  death  is  possible  as  a  result  of 
occlusion  of  cardiac  orifices.  At  times  signs  of  constriction  nf  a  cardiac 
orifice  appear  when  a  thrombus  .merely  obstructs  but  does  not  entirely 
occlude  the  orifice. 

Prognosis. — The  prognosis  is  more  favorable  in  cases  of  inflammatory 
than  in  those  of  marantic  cardiac  thrombi,  for  in  the  former  the  condition 
may  undergo  involution  to  a  certain  degree,  whereas  in  the  latter  there  is 
danger  of  increased  growth. 

Treatment. — The  treatment  is  purely  symptomatic,  and  should  be 
directed  against  individual  prominent  symptoms. 


52  CIRCULATORY  ORGANS 

111.    DISEASES   OF  THE   PERICARDIUM. 


INFLAMMATION  OF  THE  PERICARDIUM 
(PERICARDITIS). 

Htiology. — Like  most  inflammations  in  human  beings,  inflam- 
mation of  the  pericardium  also  probably  results  only  when  bacteria 
capable  of  exciting  inflammation  have  gained  access  to  the  peri- 
cardium. In  addition  to  the  usual  exciting  agents  of  suppuration 
(Streptococcus  pyogenes.  Staphylococcus  pyogenes  aureus  and  albus) 
specific  bacteria,  especially  tubercle-bacilli,  also  act  as  etiologic 
factors.  The  agencies  otherwise  mentioned  as  causes  of  the  dis- 
order have  only  the  significance  of  contributory  and  accessory 
influences  for  the  infection. 

Inflammation  of  the  pericardium  occurs  most  frequently  in  the 
sequence  of  infectious  diseases.  The  most  prominent  position  in 
this  connection  is  occupied  by  acute  articular  rJteumatisrn,  which 
not  rarely  gives  rise  at  the  same  time  to  endocarditis  and  peri- 
carditis, and  even  also  to  myocarditis.  Exposure  to  cold,  injuries,  and 
debilitating  diseases  (chronic  nephritis,  carcinoma,  long-continued 
suppuration,  scorbutus,  purpura,  leukemia)  likewise  favor  infection 
of  the  pericardium.  At  times  the  condition  arises  by  extension 
from  contiguous  inflammation.  Pericarditis  is  associated  with  espe- 
cial frequency  with  left-sided  ]ileurisy.  In  some  instances  peri- 
carditis occurs  after  preexisting  disease  of  the  pericardiiun  of  other 
nature  ;  thus  after  carcinoma,  sarcoma,  tuberculosis,  and  gumma. 
At  times  no  cause  whatever  is  elicitable — spontaneous  pericarditis. 
Under  such  conditions  the  disease  is  often  tuberculous.  The  in- 
fection is  engendered  with  especial  frequency  by  tuberculosis  of 
the  tracheobronchial  lymphatic  glands.  Experience  has  shown 
that  inflammation  of  the  pericardium  occurs  most  frequently  in 
men,  and  at  the  best  period  of  life. 

Anatomic  Alterations. — Accordingly  as  pericarditis  is  at- 
tended with  the  development  of  a  fibrinous  or  a  fluid  exudate, 
a  distinction  is  made  between  pericarditis  sicca  (dry  pericarditis) 
and  pericarditis  humida    (pericarditis  with  efusion). 

In  pericarditis  sicca  s.  fibrinosa  (dry  or  fibrinous  pericarditi.<i) 
the  surface  of  the  pericardium  is  at  first  found  to  be  dull,  as  if 
moistened  with  vapor  and  covered  with  a  thin,  veil-like  fibrinous 
membrane,  M'hich  can  be  detached  with  a  knife.  Beneath  this 
the  pericardial  tissue  a]>pears  reddened.  The  fibrinous  membrane 
gradually  becomes  thicker,  more  opaque,  more  deeply  yellow,  and 
in  consequence  of  the  movements  of  the  layers  of  the  pericardium 
upcm  one  another  the  surface  acquires  an  irregular,  rough,  and 
papillary  appearance,  by  reason  of  which  the  terms  villous  heart, 


INFLAMMATION  OF  THE  PERICARDIUM  53 

for  hirsutiim  (cor  villosum  s.  tomentosum)  have  been  employed.  The 
appearance  of  such  a  heart  has  also  been  compared  with  that  of  a 
sponge,  of  a  honeycomb,  of  the  fourth  stomach  of  ruminants,  or  of 
two  surfaces  of  buttered  bread  that  have  been  separated.  As 
a  rule,  fibrinous  pericarditis  involves  simultaneously  both  peri- 
cardium and  epicardium.  Only  rarely  is  one  of  the  layers  of  the 
pericardium  alone  inflamed.  In  accordance  with  the  extent  of 
the  inflammation  a  circumscribed  (local)  and  a  diffuse  (total)  peri- 
carditis are  distinguished. 

Pericarditis  humida  (pericarditis  with  effusion)  usually  develops 
from  a  fibrinous  pericarditis,  the  formation  of  a  fluid  exudate  being 
superadded  to  the  deposition  of  fibrinous  coagula.  If  the  inflam- 
matory fluid  is  deficient  in  cells  and  still  to  a  certain  degree  trans- 
parent, the  condition  is  described  as  serous  pericarditis  or,  more 
accurately,  serofibrinous  pericarditis.  Under  other  conditions  the 
exudate  resembles  the  pus  of  an  ordinary  abscess — purulent  peri- 
carditis or  pyopericardium.  Finally,  the  effusion  may  be  bloody — 
hemorrhagic  pericarditis.  At  times,  in  consequence  of  the  presence 
of  putrefactive  bacteria,  putrid  decomposition  takes  place  in  a 
purulent  effusion — putrid  pericarditis.  This  occurs  especially  as 
a  result  of  septic  influences ;  for  instance,  puerperal  fever.  The 
amount  of  fluid  exudate  may  exceed  three  liters,  so  that  the  peri- 
cardium appears  tensely  distended,  and  when  punctured  the  fluid 
is  ejected  in  a  stream.  It  is  worthy  of  note  that  the  heart-muscle, 
by  reason  of  its  weight,  sinks  in  the  exudate,  and  that  especially 
the  portions  contiguous  to  the  pericardium  exhibit  inflammatory 
softening.  Microscopically  such  portions  are  found  to  participate 
in  the  inflammatory  process. 

Pericarditis  but  rarely  undergoes  recovery  without  leaving 
alterations  in  the  pericardium.  Of  subordinate  importance  are 
tendinous  thickenings  of  the  epicardium — tendinous  spots,  maculce 
tendine/e  s.  albidce,  also  designated  insulse.  Frequently  connective- 
tissue  adhesions  take  place  between  the  two  layers  of  pericardium 
(pericardial  synechice  or  adhesions).  These  sometimes  cause  com- 
plete obliteration  of  the  pericardial  cavity — obliteratio  s.  concretio 
pericardii.  At  times  the  synechise  contain  inspissated,  cheesy, 
or  calcareous  remnants  of  the  fluid  exudate.  In  rare  cases  almost 
the  entire  heart  appears  to  be  enclosed  in  a  calcareous  capsule. 
At  times  the  inflammation  extends  from  the  pericardial  cavity  to 
the  outer  surface  of  the  pericardium — external  pericarditis.  Under 
such  conditions  also  connective-tissue  adhesions  may  form  in  the 
course  of  time,  and  these  may  surround  the  large  arteries  and 
the  venous  trunks  of  the  heart,  and  possibly  bind  the  pericar- 
dium to  the  sternum  and  to  the  vertebral  column.  Such  altera- 
tions have  been  designated  indurative  or  fibrous  media stinoperi- 
carditis. 

Symptoms. — Pericarditis  can  be  recognized  only  from  the 


54 


CIRCULATORY  ORGANS 


'phynical  alterations   in   the  heart.     Constitutional  symptoms  are 
wanting:  or  are  only  of  indefinite  nature. 

FibrinoiL.^  pericarditis  is  disclosed  by  the  occurrence  of  a  peri- 
carditic  friction-mumiur.  This  is  characterized  by  its  superficial, 
rasping  character,  by  not  being  confined  strictly  to  the  cardiac 
phases,  and  by  usually  exhibiting  numerous  interruptions  which 
are  dependent  upon  the  movements  of  the  auricles  and  the  ven- 
tricles. It  is  at  tin)es  so  loud  that  it  can  be  felt  with  the  hand 
as  pericardial  friction  or  aff'rictus  pericardiacus,  and  that  the 
patient  may  himself  be  conscious  of  its  presence  in  the  thorax  as 


Fig.  8.— Area  of  cardiac  percussion-dulness  in  a  case  of  pericarditis  witli  efFiision  :  X, 
situation  of  the  apex-beat.    From  a  photograph  (personal  observation,  Znrich  clinic). 


a  rubbing.  Pericardial  friction-murmurs  are  usually  confined  to 
the  area  of  cardiac  duhiess,  or  they  are  diffused  in  any  event  for 
but  a  short  distance  l)eyond.  They  are  intensified  l)y  the  pressure 
of  tiie  stethoscope.  Their  intensity  varies  also  with  the  position 
of  the  body,  and  is  increased  as  a  rule  by  over-inclination  for- 
ward. Frequently  ])ericardial  friction-murmurs  are  audible  for 
days  and  -weeks  ;  at  times,  however,  for  only  a  few  hours,  because 
the  inflammation  is  sometimes  of  but  short  duration. 

Pericarditis  with  Jin  id  e fusion  first  leads  to  increase  in  size  and 


INFLAMMATION  OF  THE  PERICARDIUM  55 

change  in  shape  of  the  area  of  cardiac  dulness.  This  is  induced 
by  distention  of  the  pericardium  by  the  fluid.  The  area  of  car- 
diac dulness  is  increased  both  to  the  right  and  the  left,  and  from 
above  downward,  and  at  the  same  time  it  assumes  the  shape  of  a 
trapezoid  (Fig.  8). 

In  the  diagnosis  it  is  important  that  frequently  the  area  of 
cardiac  dulness  extends  to  the  left  beyond  the  apex-beat,  because 
the  fluid  in  the  pericardial  cavity  is  distributed  to  the  right  and 
the  left  beyond  the  borders  of  the  heart.  G-radual  disappearance 
of  the  apex-beat  in  the  course  of  the  disease  is  likewise  a  valuable 
sign  because  layers  of  exudate  gradually  increasing  in  thickness 
are  deposited  upon  the  anterior  surface  of  tlie  heart,  and  the  heart- 
muscle  becomes  the  more  deeply  submerged.  In  consequence 
diminution  in  the  intensity  of  the  heart-sounds  also  takes  place. 

Among  symptoms  of  more  subordinate  significance  may  be  mentioned 
marked  bulging  of  the  precordium  in  consequence  of  pressure  exerted  by 
the  pericardial  exudate  and  inflammatory  paresis  of  the  intercostal  mus- 
cles, and  cutaneous  edema  in  the  precordium,  the  latter  resulting  from  the 
collateral  edema. 

In  the  majority  of  cases  pericardial  friction-murmurs  are  en- 
countered in  addition  to  signs  of  accumulation  of  fluid  in  the 
pericardium,  as  usually  besides  fluid  effusion  fibrinous  inflammatory 
products  are  present.  Friction-murmurs  are  absent  only  when 
copious  fluid  effusions  have  been  poured  out,  because  then  a 
rubbing  upon  each  other  of  the  layers  of  the  pericardium  is 
impossible.  Such  murmurs  appear  only  when  a  portion  of  the 
fluid  exudate  has  undergone  absorption. 

Constitutional  symptoms  may  be  entirely  wanting  in  cases  of 
inflammation  of  the  pericardium.  Frequently  irregular  febrile 
movement  is  present.  Not  rarely  the  patients  complain  of  a  sense 
of  constriction,  of  pressure,  and  even  of  pain  in  the  precordium. 
The  action  of  the  heart  appears  accelerated  and  irregular,  and  the 
radial  pulse  is  conspicuous  for  its  slight  tension. 

The  duration  of  inflammation  of  the  pericardium  may  extend 
over  several  months. 

One  of  the  most  frequent  and  most  serious  complications  is 
myocardial  weahiess,  with  symptoms  of  stasis,  and  a  considerable 
number  of  patients  die  in  consequence  of  increasing  edema. 
Sudden  paralysis  of  the  heart,  for  instance  from  carelessness  in 
assuming  the  sitting  or  the  erect  posture,  is  less  common.  At 
times  manifestations  due  to  pressure  of  the  pericardial  exudate 
upon  neighboring  organs  occur.  Thus,  there  may  be  unilateral 
or  even  bilateral  paralysis  of  the  recurrent  laryngeal  nerve,  con- 
striction of  the  esophagus,  obstinate  singultus,  and  vomiting. 
Frequently  the  lower  lobe  of  the  left  lung  is  compressed  until 
all  of  its  air  is  expelled,  with  the  development  of  dulness  on 
percussion,  increased  vocal  fremitus,  and  bronchial  breathing.     At 


56  CIRCULATORY  ORGANS 

times  tlie  inflammation  of  the  pericardium  extends  to  the  pleura, 
and  then  pleurisy  is  superadded,  usually  left-sided.  Not  rarely 
attacks  of  accelerated  heart-action  and  di/spnea  occur  which  may 
be  excited  by  physical  or  mental  exertion,  but  which  appear  also 
during  states  of  profound  rest. 

Rupture  of  a  pericardial  effusion,  with  the  formation  of  an  external  or 
an  internal  pericardial  fistula,  may  be  mentioned  as  an  unusually  rare 
complication. 

When  pericarditis  terminates  in  recovery  a  morbid  hyperirri- 
tability  of  the  myocardium  often  persists  for  a  considerable  time, 
and  which  is  manifested  in  a  marked  tendency  to  accelerated  and 
irregular  cardiac  action.  Among  the  residua  of  pericarditis  ten- 
dinous spots  are  unattended  with  symptoms  ;  in  only  one  instance 
have  I  been  able  to  detect  friction-murmurs  over  an  especially 
dense  and  thick  tendinous  spot.  Pericardial  adhesions  also  are 
unattended  with  symptoms  so  long  as  they  do  not  affect  the  cir- 
culation in  the  coronary  arteries  of  the  heart  and  the  movements 
of  the  heart-muscle.  If  the  coronary  arteries  are  constricted  by 
adhesions,  the  nutrition  of  the  myocardium  must  suffer,  and  signs 
of  cardiac  iveakness  and  stasis  appear,  to  which  the  patient  finally 
succumbs.  Adhesions  that  interfere  with  the  systolic  movement 
of  the  heart  downward  give  rise  to  systolic  retraction  in  the  region 
of  the  apex-beat  with  the  systolic  shortening  of  the  heart.  This 
becomes  especially  marked,  and  involves  also  the  contiguous  tho- 
racic wall,  w^hen  the  apex  of  the  heart  is  adherent  to  the  inner 
aspect  of  the  chest,  and  is  capable  of  exerting  direct  traction  on 
the  chest-wall.  Indurcdive  mcdiastinopericarditis  is  indicated  by 
an  intermittent  inspiratory  or  paradoxic  pulse  and  inspiratory  dis- 
tention of  the  cervical  veins.  Naturally,  these  are  not  unequivocal 
symptoms,  for  similar  manifestations  are  sometimes  observed  also 
in  association  with  pericarditis,  pleurisy,  and  aneurysm  of  the 
aorta.  Both  the  diminution  in  size  and  even  the  disappearance 
of  the  pulse  during  inspiration  and  the  synchronous  increased  dis- 
tention of  the  cervical  veins  may  be  explained  by  the  fact  that 
the  aorta  and  the  vena  cava  are  surrounded  by  adhesions,  and 
their  lumen  becomes  constricted  by  traction  during  inspiration. 

Diagnosis. — Vi^henever pericard ial friction-mnrmnrs arc  heard 
fibrinous  jicricarditis  may  be  diagnosed,  for  it  is  extremely  rare  for 
heniorrhages,  excessive  dryness  (in  cases  of  Asiatic  cholera)  or 
tendinous  patches  of  the  pericardium,  to  give  rise  to  such  murmurs. 
Pericardial  murmurs  may  be  confounded  with  endocardial  and 
pleuropericardial  (external  pericardial)  murmurs. 

In  coiitradi><tinction  from  endocardial  7nurmur>t  pericardial  murmurs 
apjiear  more  superficial  and  rasping-,  and  are,  as  a  rule,  not  audible  beyond 
the  limits  of  cardiac  percussion-dulness.  They  are  not  strictly  confined  to 
the  cardiac  phases,  and  usually  permit  the  recognition  of  a  number  of  inter- 
ruptions.     During   inspiration   they   do   not,   like   endocardial   murmurs, 


INFLAMMATION  OF  THE  PERICARDIUM  57 

become  fainter,  but  louder,  because  the  dilating  lung  exerts  pressure  ujion 
the  layers  of  the  pericardium  and  favors  their  rubbing  upon  each  other. 
They  may  also  be  increased  by  pressure  with  the  stethoscope,  and  they  vary 
greatly  in  intensity  with  the  posture  of  the  body. 

Pleuropericardial  friction-murmurs  occur  with  an  intact  pericardium 
when  fibrinous  pleurisy  has  developed  in  close  proximity  to  the  pericar- 
dium, so  that  the  movements  of  the  heart  give  rise  to  pleural  friction- 
murmurs.  The  dependence  of  doubtful  murmurs  upon  respiration  may, 
however,  usually  be  demonstrated  by  deep  inspirations.  If  the  breath  be 
held  after  deep  inspiration,  the  pericardial  influences  are  suspended,  and  in 
general  they  do  not  appear  when  the  breath  is  held. 

In  the  presence  of  pericarditis  with  effusion  there  is  a  possi- 
bility of  confounding  the  enlarged  area  of  cardiac  percussion-dul- 
ness  with  dilatation  of  the  heart.  It  is  then  important  to  determine 
whether  the  area  of  cardiac  dulness  extends  to  the  left  beyond  the 
apex-beat,  which  is  indicative  of  the  presence  of  fluid  in  the  peri- 
cardium, and  whether  the  apex-beat  gradually  disappears  in  the 
course  of  the  disease.  When  pericarditis  with  effusion  is  present 
the  heart-sounds  become  faint  and  the  action  of  the  heart  is 
scarcely,  if  at  all,  visible.  Gerhardt  has  further  called  attention 
to  the  displacement  upward  of  the  upper  limit  of  cardiac  dulness 
in  the  sitting  posture  in  cases  of  pericarditis. 

Sacculated  pleuritic  effusions  and  infiltration  of  the  median  borders  of  the 
lungs  may  give  rise  to  increase  in  the  area  of  cardiac  dulness  and  to  errors 
in  diagnosis;  but  the  dulness  then  usually  assumes  an  irregular  shape,  and 
when  infiltration  of  the  lung  is  present  bronchial  breathing  is  audible. 

The  character  of  the  effusion  can  be  determined  with  certainty 
only  by  exploratory  puncture  of  the  pericardium;  otherwise  de- 
pendence must  be  placed  upon  the  results  of  clinical  experience, 
which  show  that  acute  articular  rheumatism  is  usually  attended 
with  serofibrinous,  septic  processes  with  purulent,  and  scorbutus, 
tuberculosis,  sarcoma,  and  often  also  nephritis,  with  hemorrhagic 
effusions. 

Prognosis. — Pericarditis  Is  under  all  circumstances  a  serious 
disease.  Even  the  cases  that  at  first  appear  to  be  mild  may  with 
insufficient  care  acquire  a  grave  character.  Of  great  importance 
with  relation  to  the  prognosis  is  the  etiology.  Wliile  pericarditis 
in  the  sequence  of  acute  articular  rheumatism  is  usually  followed 
by  recovery,  the  prognosis  wlien  septic  factors  are  operative  is 
materially  more  serious,  and  in  the  presence  of  new-formations  it 
is  invariably  unfavorable. 

Treatment. — All  varieties  of  pericarditis  require  the  same 
general  treatment  (rest  in  bed,  easily  digestible  diet,  especially  milk 
and  soups).  Further  than  this  the  treatment  will  vary  with  the 
character  of  the  exudate.  In  cases  of  fibrinous  pericarditis  an 
ice-bag  should  be  applied  continuously  to  the  precordium,  and  if 
severe  pain  or  marked  dyspnea  be  present  an  injection  of  morphin 
should  be  s^iven  : 


58  CIRCULATORY  ORGANS 

R     Morphin  hydrochlorate  0.3  (4i  grains) ; 

Glycerin, 

Distilled  water,  each  5.0  (75  minims). — M. 

Dose:  0.5  c.c.  (8  minims)  subcutaneously. 

If  tlie  action  of  the  heart  be  accelerated,  enfeebled,  and  irreg- 
ular, digitalis  should  be  prescribed  : 

li     Powdered  digitalis-leaves,  0.1  (1 J  grains)  ; 

Diuretin,  1.0  (15  grains); 

Sugar,  0.5  (7^  grains). — M. 

Make  ten  such  powders. 
Dose  :  1  powder  every  three  hours. 

In  cases  of  serous  2i^r{carditis  also  a  similar  course  of  treat- 
ment may  be  recommended.  From  sorbefacients  (potassium 
iodid  internally,  potassium-iodid  ointment  or  iodoform-ointment 
by  inunction,  and  tincture  of  iodin  applied  locally)  no  great 
measure  of  success  is  to  be  expected.  At  times  repeated  applica- 
tion of  an  ordinary  cantharidal  plaster  will  hasten  the  absorption 
of  the  effusion.  If  absorption  fails  to  take  place  after  the  lapse 
of  weeks,  or  if  perhaps  after  the  fourth  week  the  amount  of 
effusion  increases,  or  if  it  is  from  the  outset  so  extensive  that  death 
is  threatened  through  interference  with  the  action  of  the  heart, 
artilicial  evacuation  of  the  effusion  by  puncture  of  the  pericardium 
may  be  recommended. 

Purulent  pericardial  effusions  should  be  evacuated  immediately 
by  opening  the  pericardium  with  a  knife,  because  experience  has 
taught  that  absorption  cannot  be  effected  by  any  means,  and  if 
delay  be  too  much  prolonged  irremediable  cardiac  weakness  will 
develop.  The  same  statement  applies  to  putrid  p>ericarditis. 
Hemorrhagic  pericarditis  has  been  observed  to  assume  such  enor- 
mous proportions  in  cases  of  scorbutus  that  puncture  of  the  peri- 
cardium was  necessitated. 

PNEUMOPERICARDIUM, 

Anatomic  Alterations, — Pneumopericardium  signifies  an  accumulation 
of  gas  in  tite  ppricanUal  cavihf.  If  the  amount  of  gas  be  considerable,  the 
pericardium  is  tensely  distended,  and  when  punctured  the  gas  escapes  with 
a  hissing  sound.  As  a  rule,  pure  pneumopericardium  is  not  encountered, 
but  a  liiidrojtneiimnpericardinm  ;  that  is,  in  addition  to  gas  fluid  also  is  present 
in  the  ])ericardial  cavity.  Accordingly  as  this  fluid  is  serum,  pus,  or  blood, 
a  distinction  is  made  between  sernpncvrnopcricardium,  pyopneumopericardinm, 
and  hetnnpneiimnpfricardium.  The  pericardium  at  the  same  time  presents 
evidences  of  inflammation. 

Etiology. — Pneumopericardium  is  a  rare  disease.  It  develops  when  the 
pericardia/  carifij  commynirafes  vifli  air-confaininq  vis^cera  or  through  the 
thoracic  wall  directly  with  the  external  air.  Such  occurrences  have  been 
observed  in  cases  of  ruptured  pulmonary  cavities,  carcinoma  of  the  esoph- 
agus, gastric  ulceration,  carcinoma  of  tiie  stomach,  rupture  of  purulent  w 
pericardial  eff'usions  into  air-containing  viscera,  or  externally,  injuries  of  ' 
the  chest-wall,  and  the  like. 

It  has  been  maintained  that  a  pyopneumopericardium  may  be  developed 


DROPSY  OF  THE  PERICARDIUM  59 

from  a  pyopericardium  bij  decomposition  of  the  pus.    This  possibility  must  be 
conceded,  as  gas-generating  bacteria  are  known  to  exist. 

Symptoms  and  Diagnosis. — The  si/7npioms  of  pneumopericardium  consist 
in  disappearance  of  the  area  of  cardiac  dulness  in  the  dorsal  decubitus,  and 
the  presence  instead  of  signs  of  a  smooth-walled  cavity :  a  metallic  percussion- 
note,  which  is  brought  out  with  especial  distinctness  when  auscultatory  per- 
cussion is  practised  with  the  aid  of  a  plexor  and  plexinieter.  'n\Q  heart- 
sounds  in  consequence  of  the  resonance  also  seem  to  possess  a  metallic  char- 
acter, like  a  bell.  If  the  air-fistula  be  patulous,  percussion  further  will 
yield  a  cracked-pot  sound.  In  the  sitting  posture,  and  on  bending  forward, 
the  heart  will  become  again  applied  to  the  chest-wall,  and  can  then  be 
demonstrated  by  the  dulness  on  percussion. 

A  pericardial  splashing-sound  is  distinctive  of  hydropneumopericardium 
{water-wheel  murmur).  This  is  developed  by  the  movement  to  and  fro  of  the 
fluid  contents  of  the  pericardium  through  the  action  of  the  heart.  At  times  it 
may  be  heard  at  some  distance  from  the  patient.  In  addition  changes  in  the 
percussion-phenomena  take  place  in  accordance  with  the  position  of  the  body. 
These  are  dependent  upon  the  fact  that  the  fluid  always  seeks  the  lowest 
level,  and  over  it  dulness  exists,  while  the  gas-generating  cavity  yields  a 
metallic  note  on  percussion. 

Patients  with  pneumopericardium  and  hydropneumopericardium  com- 
plain mostly  of  a  sense  of  constriction  and  even  of  pain  in  the  precordiuni, 
while  the  action  of  the  heart  is  accelerated  and  often  irregular;  they  suffer 
from  dyspnea  and  threatening  weakness  of  the  heart,  because  the  free  move- 
ment of  the  organ  is  prevented.  Weakness  of  the  heart-muscle  2ind  paralysis 
of  the  heart  are  the  principal  dangers  of  the  disease. 

Prognosis. — The  prognosis  is  unfevorable  because  of  the  serious  nature 
of  the  primary  disorder,  independently  of  the  dangers  that  attend  pneumo- 
pericardium and  hydropneumopericardium  themselves. 

Treatment. — In  cases  of  pneumopericardium  and  hydropneumopericar- 
dium efforts  should  first  be  made  to  allay  fear  and  dyspnea  by  means  of  a 
subcutaneous  injection  of  morphin.  Should  the  collection  of  gas  be  consider- 
able, the  pericardium  may  be  punctured  by  means  of  a  hollow  needle,  whose 
free  extremity  is  covered  with  a  rubber  tube,  the  other  end  of  which  is 
placed  beneath  the  surface  of  a  solution  of  carbolic  acid  (5  :  100).  In  cases 
of  pyopneumopericardium  the  pericardium  should  be  opened  by  incision, 
while  in  cases  of  seropneumopericardium  and  hemopneumopericardium 
puncture  of  the  pericardium,  with  subsequent  treatment  as  in  cases  of  serous 
and  hemorrhagic  pericarditis  will  suffice. 

DROPSY  OF  THE  PERICARDIUM 
(HYDROPERICARDIUM) . 

Anatomic  Alterations. — The  accumulation  of  a  serous  transudate  in  the 
pericardial  cavity  is  known  as  hydropericardium.  The  pericardium  always 
contains  a  certain  amount  of  serous  fluid,  so  that  hydropericardium  is  only 
spoken  of  when  the  pericardial  cavity  contains  more  than  100  c.c.  of  clear, 
amber-yellow  fluid.  The  amount,  however,  may  reach  several  liters.  Xot 
rarely  the  pericardial  tissue  api)ears  edematous,  and  the  myocardium  pale 
and  saturated  with  fluid.  Hydropericardium  is  distinguished  from  a  serous 
exudate  by  the  absence  of  flocculi  and  the  clear  appearance  of  the  fluid. 

Etiology. — Transudation  into  the  pericardial  cavity  results  from  causes 
similar  to  those  that  bring  about  transudation  into  other  serous  cavities 
and  into  the  subcutaneous  connective  tissue,  with  which  it  is  thus  usually 
found  in  association.  The  condition  present,  therefore,  is  usually  one  of 
cachexia  or  of  increase  of  pressure  in  the  venotis  system.  It  is  observed  quite 
frequently  in  association  with  diseases  of  long  standing,  such  as  pulmonary 


60  CIRCULATORY  ORGANS 

tuberculosis,  carcinoma,  suppuration,  nephritis,  respiratory  and  cardiac  dis- 
ease. Rarely,  local  causes  of  stasis  are  present  in  the  coronary  veins,  in 
consequence  of  adhesions  or  tumors  of  the  pericardium. 

Symptoms  and  Diagnosis. — Dropsy  of  the  pericardium  gives  rise  to 
the  same  local  cardiac  alterations  as  a  collection  of  pericardial  fluid  exudate, 
except  that  a  pericardial  friction-murmur  is  wanting.  The  area  of  cardiac 
duliiess  is  increased  in  extent,  and  projects  beyond  the  apex-beat  outward 
toward  the  left,  tiie  apex-beat  becomes  feebler  and  finally  disappears,  and 
the  heart-sounds  are  faint.  In  addition  there  are  signs  of  v:eakness  of  the 
heart,  which  is  induced  in  part  by  the  primary  disorder,  and  in  part  by 
interference  with  the  action  of  the  heart.  Usually  there  is  complaint  of 
marked  dyspnea  and  a  sense  of  constriction,  because  the  movement  of  the 
lungs  and  of  the  diaphragm  is  embarrassed  by  coexisting  hydrothorax  and 
ascites.  Death  in  consequence  of  jjaralysis  of  the  heart  is  the  most  frequent 
termination. 

Prognosis. — Dropsy  of  the  pericardium  is  not  unjustly  in  evil  repute 
among  the  laity,  for  frequently  it  is  associated  with  incurable  conditions, 
and,  besides,  the  disorder  itself  is  attended  with  the  danger  of  cardiac  weak- 
ness and  paralysis  of  the  heart.  Eecovery  is,  however,  possible  if  the  cause 
can  be  removed. 

Treatment. — Treatment  should  in  the  first  place  be  caiisal.  Symptom- 
atically  resort  will  often  be  had  especially  to  heart-tonics,  and  particularly 
to  digitalis  and  diuretin.  Extensive  transudates  require  puncture  of  the 
pericardium. 

HEMOPERICARDIUIVL 

Accumulations  of  blood  in  the  pericardial  cavity  occur  especially  in 
association  with  injuries  and  rupture  of  the  heart  and  of  aneurysms  of  the 
a/)rta,  2^iil>'ionary  artery,  or  coronary  arteries.  Their  recognition  depends 
upon  the  fact  that  the  area  of  cardiac  percussion-dulness  increases  rapidly  in 
consequence  of  the  increasing  accumulation  of  blood,  while  the  apex-beat 
disappears  and  the  sounds  of  the  heart  become  fainter,  and  at  the  same  time 
manifestations  of  internal  hemorrhaye  appear.  Death  may  result  from  hem- 
orrhage  or  in  consequence  of  parali/sis  of  the  heart.  The  prognosis  is,  there- 
fore, always  serious.  Therapeutically  stimula7its  may  be  recommended; 
for  instance,  camphorated  oil  (a  syringeful  subcutaneously  every  two  to 
four  hours).  Not  much  will  be  accomplished  by  the  use  of  hemostatics  (ice- 
bag,  subcutaneous  injection  of  extract  of  ergot,  fluid  extract  of  hydrastis, 
twenty-five  drops  thrice  daily,  etc.).  I  have  averted  death  in  one  case  by 
puncture  of  the  pericardial  cavity  and  aspiration  of  the  blood. 

CHYLOPERICARDIUM. 

In  rare  instances  lacteal  vessels  rupture  and  an  accumulation  of  chyle 
takes  place  in  the  pericardial  cavity,  which,  if  in  sufficient  amount,  may 
give  rise  to  an  increase  in  the  area  of  cardiac  percussion-dulness. 

TUMORS    OF    THE   PERICARDIUM    <NEOPLASMATA 

PERICARDH). 

Tumors  of  the  pericardium  (carciiKima,  sarcoma,  fibroma,  enchondroma, 
lymphoma)  are  rare.  They  are  often  unrecognized  during  life.  Carcino- 
mata  and  sarcomata,  which  are  almost  always  secondary,  are  likely  to  be 
associated  with  pericarditis  with  efi'usion,  and  this  is  frequently  hemor- 
rhagic. This  latter  condition  may  be  recognized  ;  but,  as  a  rule,  it  is  only 
learned  at  autopsy  that  the  new-formations  in  the  pericardium  were  the 
actual  cause. 


PABOXYSiMAL   TACHYCARDIA  61 


IV.    CARDIAC   NEUROSES. 


PAROXYSMAL  TACHYCARDIA. 

Symptoms  and  Diagnosis. — Paroxysmal  tachycardia  is 
characterized  by  attacks  of  accelerated  cardiac  activity.  These 
sometimes  occur  without  demonstrable  cause,  while  at  other  times 
they  follow  upon  physical  or  mental  exertion,  gastric  derange- 
ment, the  use  of  coffee,  tea,  alcohol,  and  the  like.  The  number 
of  heart-beats  may  exceed  two  hundred  in  the  minute,  and  they 
often  follow  one  another  so  precipitately  that  each  contraction 
of  the  heart  is  not  sufficient  to  induce  a  palpable  pulse  in  the 
radial  artery.  Not  rarely  there  is  also  irregularity  in  the  action 
of  the  heart. 

Sphygmographic  observations  usually  disclose  alterations  in  the  pulse- 
wave,  lu  consequence  of  reduction  in  tension  the  pulse  is  frequently  mono- 
crotic or  anacrotic. 

As  a  rule,  local  cardiac  alterations  are  demonstrable.  The 
precordium  is  shaken  and  raised  with  unusual  vigor,  and  through- 
out an  increased  extent,  and  the  systolic  sound  of  the  heart  at 
times  acquires  a  clattering  character,  which  has  been  designated 
cliqueties  m^tallique,  and  has  been  attributed  to  vibrations  of  the 
chest-wall.  At  times  dilatation  of  the  right  ventricle  takes  place. 
Generally  active  pulsation  of  the  carotids  in  the  neck  is  observed. 

Among  subjective  disturbances  the  distressing  sense  of  ham- 
mering and  beating  in  the  chest  predominates.  Besides,  a  sense 
of  fear,  of  constriction,  shortness  of  breath,  and  accelerated  breath- 
ing are  noticeable.  Not  rarely  pallor,  cyanosis,  and  marked 
venous  distention  are  observed. 

The  attack  may  terminate  quite  suddenly.  At  times  its  termi- 
nation is  preceded  by  eructation,  vomiting,  discharge  of  flatus, 
intestinal  contents,  or  pale,  watery  urine.  The  duration  of  an  attack 
may  vary  between  a  few  minutes  and  several  days.  While  some 
patients  are  subjected  to  only  a  single  attack  or  but  a  few  attacks, 
others  may  have  several  attacks  daily  for  years,  and  at  times 
throughout  the  whole  of  life,  so  that  the  disorder  may  become  a 
burdensome  affliction.  A  fatal  termination  is  rare,  but  may  occur 
in  consequence  of  paralysis  of  the  heart,  enfeeblement  of  the 
heart-muscle,  and  stasis  or  cerebral  hemorrhage. 

The  recognition  of  the  disease  is  easy  from  its  paroxysmal  occur- 
rence, by  which  it  is  distinguished  from  the  accelerated  activity 
of  the  heart  that  develops  when  unusual  resistance  is  interposed 
to  the  arterial  blood-current,  as,  for  instance,  with  uncompensated 
valvular  lesions  of  the  heart. 


G2  CIRCULATORY  ORGAXS 

It  is  notewoitby  that  some  j)ersons  complain  of  all  of  the  symptoms  of 
paroxysmal  tachycardia  without  the  action  of  the  heart  being  at  ail  accel- 
erated. For  this  reason  a  distinction  has  been  made  between  subjective  and 
objective  palpitation  of  the  heart. 

It  is  important  in  cverv  case  to  determine  the  cauHe  of  the  (Un- 
order, because  the  prognosis  and  treatment  are  dependent  upon  it. 

Acceleration  of  the  action  of  the  heart  ruay  take  place  in  consequence 
oi paralysis  of  the  vagus  or  of  irritation  of  the  si/mpathefic.  The  former  appears 
to  occur  the  more  frequently,  and  may  be  assumed  to  exist  when  jsressure 
upon  the  vagus  in  the  neck  speedily  brings  the  attack  to  an  end.  On  the 
other  hand,  in  cases  of  tachycardia  due  to  irritation  of  the  sympathetic  mor- 
phin  will  often  cause  speedy  subsidence  of  the  attack.  A  positive  differ- 
entiation, however,  can  frequently  not  be  made. 

Ktiologfy. — Persons  with  a  readif//  irritable  nervous  system 
are  especially  predisposed  to  paroxysmal  tachycardia.  Among 
the  actual  causes  are  at  times  diseases  of  the  nerves,  and  at  other 
times  reflex  irritation.  Not  rarely  the  disorder  develops  in  the 
course  of  certain  central  neuroses,  particularly  hysteria,  neuras- 
thenia, and  hypochondriasis.  PsycMc  disturbances  also  play  an 
important  etiologic  role  ;  for  instance,  joy,  fright,  grief,  fear,  em- 
barrassment, nostalgia,  and  disappointment  in  love.  At  times 
toxic  influences  may  be  operative,  such  as  excessive  use  of  alcohol, 
tobacco,  coffee,  and  tea.  The  palpitation  of  gouty  patients  possi- 
bly also  belongs  in  this  category.  At  times  paroxysmal  tachy- 
cardia develops  in  connection  with  states  of  exhaustion  of  the 
nervous  system ;  for  example,  after  severe  typhoid  fever,  loss  of 
sleep,  and  sexual  excesses.  Anatomic  alterations  in  the  central 
nervous  system  (hemorrhage,  abscess,  tumor  of  the  brain,  tabes 
dorsalis,  multiple  sclerosis,  compression  of  the  vagus  by  tumors) 
may  also  be  considered  as  causes  of  paroxysmal  tachycardia. 
The  disorder  occurs  with  especial  frequency  in  consequence  of 
reflex  irritation.  Thus  gastric,  intestinal,  hepatic,  renal,  uterine, 
and  ovarian  diseaso  may  be  followed  by  paroxysmal  tachycardia,  as 
may  also  valvular  disease  of  the  heart,  disease  of  the  myocardium, 
of  the  pericardium,  of  the  nasal  turbinate  bones,  and  even  of  the 
teeth.  Xevertheless,  there  are  still  cases  in  which  no  cause  can 
be  demonstrated.  The  disorder  occurs  more  frequently  in  women 
than  in  men,  l^ecause  in  the  former  the  nervous  system  is  more 
irritable,  and  diseases  of  the  female  generative  organs  constitute 
a  not  uncommon  point  of  origin.  Although  the  affection  is  not 
unknown  among  children  also,  it  occurs  much  more  frequently  at 
about  the  period  of  puberty. 

Anatomic  Alterations. — Distinctive  anatomic  alterations 
are  not  known.  Dilatation,  fatty  degeneration,  and  relaxation 
of  the  heart  are  secondary  manifestations.  Stix  reported  the 
occurrence  in  one  case  of  (legeneration  of  the  fibers  of  the  vagus 
from  compression  by  bronchial  glands. 


NERVOUS  HEART-PAIX  63 

Prognosis. — The  prognosis  is  favorable  only  in  such  oases  in 
\\  hicli  the  causative  condition  is  curable.  Life  is,  naturally,  not 
endangered  as  a  rule. 

Treatment. — During  the  j^uroxysm  of  palpitation  of  the  heart 
it  is  advisable  for  the  patient  to  seek  a  quiet,  slightly  darkened 
room,  to  occupy  the  horizontal  posture,  to  appl}'  an  ice-bag  to  the 
precordiura,  and  to  swallow  small  bits  of  ice,  or  water-ice.  Some 
patients  have  learned  how  to  obtain  relief  with  the  aid  of  domes- 
tic remedies,  for  instance  by  means  of  a  cup  of  black  coffee ; 
while  others  obtain  speedy  relief  from  pressure  on  and  irritation 
of  the  vagus  in  the  neck,  or  from  pressure  upon  certain  points  on 
the  abdomen.  Usually  an  attack  can  be  speedily  terminated  by 
means  of  a  subcutaneous  injection  of  morphin  : 

B     Morphin  hydrochlonite,  0.3  (4j  grains)  ; 

Glycerin, 

Distilled  water,  each,  5.0  (75  minims). — M. 

Dose:  From  0.25  to  0.5  c.c.  (4  to  8  minims)  subcutaneously. 

To  prevent  subsequent  attacks,  the  causes  of  the  disorder  must 
be  kept  in  view,  and  naturally  the  most  varied  •  measures  and 
modes  of  treatment  will  be  taken  into  consideration. 

PAROXYSMAL  BRADYCARDIA. 

Paroxysmal  bradycardia  is  characterized  by  attacks  of  unusual  infre- 
quency  of  cardiac  action,  so  that  the  pulse-beat  may  be  less  than  thirty  in 
the  minute.  In  addition  there  may  be  a  sense  of  oppression  in  the  precor- 
dium,  of  fear,  vertigo,  and  profound  syncope.  I  have  observed  such  condi- 
tions most  frequently  in  the  sequence  of  infectious  diseases,  especially  after 
acute  articular  rheumatism  and  typhoid  fever;  but  they  may  be  due  also  to 
toxic  influences  (coffee,  tea,  tobacco),  and  to  fat  heart,  chronic  myocarditis,  and 
sclerosis  of  the  coronary  arteries.  The  condition  should  not  be  confounded 
with  the  persistent  slowing  of  the  action  of  the  heart  observed  in  connection 
with  icterus,  intestinal  diseases,  and  the  puerperium.  The  horizontal  posture 
and  stimulants  (ethereal  tincture  of  valerian,  30  drops;  camphorated  oil 
subcutaneously)  are  best  adapted  to  the  relief  of  such  symptoms  as  may  be 
present. 

CARDIAC  INTERMITTENCY. 

Cardiac  intermittency  is  characterized  by  attacks  in  which  the  action  of 
the  heart  is  suspended  for  a  number  of  seconds  at  a  time,  to  be  resumed 
again  in  a  regular  manner.  During  the  attack  the  patients  complain  of  a 
sense  of  oppression,  of  fear,  and  of  a  premonition  of  death.  The  affection 
is  extremely  rare,  and  has  been  observed  in  connection  with  fat  heart,  aortic 
stenosis,  chronic  nephritis,  disease  of  the  central  nervous  system,  and  after 
bodily  and  mental  exertion.  The  treatment  consists  in  assumption  of  the 
horizontal  posture  and  the  use  of  stimulants. 

NERVOUS   HEART-PAIN    (STENOCARDIA;    ANGINA 

PECTORIS). 

Symptoms  and  Diagnosis. — Stenocardia  is  characterized 
bv  the  occurrence  of  paroxysmal  attacks  of  pain  in  the  precordium, 


64  CIRCULATORY  ORGANS 

uliich  nuiy  radiato  for  a  considerable  distance,  most  frequently  to 
the  left  arm.  The  pain  often  attains  such  a  degree  of  severity 
that  the  patients  sutler  from  a  sense  of  op})ression,  of  fear  of  death, 
with  a  pale  and  drawn  countenancre,  and  cold  sweats.  Many 
patients  obtain  relief  by  firm  pressure  of  the  hand  over  the  heart, 
or  by  applying  the  })rec()r(lium  Hrmly  against  a  solid  body,  or  by 
hastening  to  an  open  window  and  obtaining  fresh  air.  The  action 
of  the  heart  is  usually  irregular  during  the  attack  of  pain.  The 
sounds  ap])ear  faint,  as  though  masked,  and  the  pulse  is  noteworthy 
for  its  diminished  tension.  At  times  vasomotor  disturbances  appear, 
especially  in  the  form  of  cold,  pallor,  cyanosis,  formication,  and 
hyperesthesia  in  the  hands  and  arms.  In  some  cases  the  attacks 
of  pain  are  preceded  by  vasomotor  disturbances. 

Attacks  of  the  kind  described  not  rarely  occur  during  profound 
rest,  and  with  especial  frequency  during  the  act  of  going  to  sleep; 
or  they  occur  in  the  sequence, of  physical  and  mental  exertion,  after 
errors  in  diet  and  the  like.  Their  duration  varies  between  a  few 
seconds  and  several  hours.  While  in  many  instances  a  few  attacks 
occur  at  long  intervals,  in  others  they  occur  several  times  daily, 
and  they  may  thus  cause  life  to  be  a  burden.  Death  is  only  rarely 
induced  by  the  disease,  and  may  result  from  paralysis  of  the  heart, 
progressive  cardiac  weakness,  or  cerebral  hemorrhage. 

Ktiology. — Stenocardia  is  a  rare  disease,  which  usually  spares 
children,  and  is  at  all  common  only  after  thejvftieth  year  of  life.  Men 
suffer  from  stenocardia  much  more  commonly  than  women.  A 
distinction  is  made  between  symptomatic  and  essential  stenocardia. 
Symptomatic  stenocardia,  is  associated  with  diseases  of  the  circu- 
latory organs,  especially  arteriosclerosis  of  the  coronary  arteries, 
chronic  myocarditis,  fat  heart,  aortic  valvular  insufficiency,  aortic 
stenosis,  aneurysm  of  the  aorta,  and  pericardial  adhesions.  Essen- 
tial stenocardia  attacks  especially  pale,  nervous,  and  obese  indi- 
viduals. Toxic  influences  are  often  operative,  especially  excessive 
indulgence  in  tobacco,  tea,  or  alcohol.  At  times  the  affection 
arises  in  the  course  of  certain  central  neuroses,  such  as  hysteria, 
neurasthenia,  and  hypochondriasis.  At  other  times  it  has  been 
observed  to  follow  emotional  disturbance  ((lisap]iointment  in  love). 
Not  rarely  it  is  induced  by  reflex  irritation,  and  it  may  occur  as  a 
sequel  of  gastric,  intestinal,  hepatic,  uterine,  and  ovarian  disease. 
Sometimes  the  disorder  has  been  observed  to  appear  in  the  sequence 
of  infectious  diseases.  In  some  cases  it  has  developed  in  associa- 
tion with  mediastinal  tumors  and  mediastinitis.  Exposure  to  cold, 
also,  is  considered  to  be  a  cause. 

The  pa/hoge7ie.vf<  of  sfetwcardia  has  not  yet  been  determined  with  cer- 
tainty. The  hypothesis  that  attributes  the  "attacks  to  transient  conditions 
of  iscliemia  and  enfeeblement  of  the  lieart-nmscle  has  at  present  the  Largest 
number  of  adherents.  The  severe  pain  is  believed  to  result  from  involve- 
ment of  the  cardiac  plexus,  which  is  constituted  of  nerve-fibers  from  the 


ANEURYSM  OF  THE  AORTA  65 

sympathetic  and  the  vagus,  and  which  lies  close  to  the  branches  of  the  coro- 
nary arteries.  The  intimate  relations  of  this  plexus  with  the  left  brachial 
plexus  would  explain  the  pains  radiating  to  the  left  arm. 

Prognosis. — The  prognosis  depends  upon  whether  the  primary- 
disorder  is  curable  or  not,  and  is  therefore  unfavorable  in  cases  of 
symptomatic  stenocardia.  Immediate  danger  to  life  is,  as  a  rule, 
not  present.* 

Treatment. — The  treatment  of  an  attack  of  stenocardia  is  ap- 
proximately the  same  as  that  of  an  attack  of  tachycardia.  Rest,  a 
darkened  room,  fresh  air,  bits  of  ice,  an  ice-bag  to  the  precordium, 
and  subcutaneous  injections  of  morphin  are  most  likely  to  terminate 
the  attack. 

I  have  seen  no  convincing  results  from  inhalations  of  amyl  nitrite  and 
from  the  internal  use  of  nitroglycerin. 

Thorough  consideration  should  be  given  to  the  etiology,  for 
appropriate  causal  treatment  may  bring  about  a  cure  of  the  disease. 
In  accordance  with  the  conditions  present  various  remedies  will  be 
indicated,  such  as  nervines,  iron,  reduction  of  obesity,  and  meas- 
ures directed  against  gastric,  intestinal,  hepatic,  uterine  disorders, 
and  the  like. 


V.    DISEASES  OF  THE  AORTA. 


ANEURYSM  OF  THE  AORTA, 

Anatomic  Alterations. — Aneurysms  of  the  aorta  represent 
circumscribed  dilatations  of  this  vessel.  In  accordance  with  their 
form,  sacculated,  spindle-shaped,  and  cylindrio  aneurysms  are  dis- 
tinguished, although  the  surface  is  usually  not  smooth,  but  presents 
numerous  irregularities.  Accordingly  as  the  entire  or  onlv  a 
portion  of  the  transverse  section  of  the  vessel  is  involved  in  the 
dilatation,  the  condition  is  designated  as  axial  or  peripheral. 
Aneurysms  vary  in  size  between  a  dilatation  of  the  vessel  just 
appreciable  and  the  circumference  of  an  adult  head,  and  even 
more.  The  most  common  seat  of  aneurysms  of  the  aorta  is  the 
ascending  portion  of  the  vessel ;  then  follow  the  arch  and  the 
descending  portion.  Usually  there  is  but  a  single  aneurysm, 
although  several  are  known  to  have  been  present  in  the  same 
patient. 

When  an  aneurysm  is  opened,  its  cavity  is  usually  found  filled 
with  old  and  recent  thrombi,  which  may  be  so  considerable  in 
amount  that  the  dilatation  of  the  aortic  blood-current  is  neutral- 

^  Death  in  an  attack  of  angina  pectoris  is,  however,  not  rare. — A.  A.  E. 
5 


66 


CIRCULATORY  ORGANS 


ized.     The  rcall  of  the  cnieuri/.sm  is  usually  the  seat  of  cndartcritic 
alterations  (fatty  degeneration  and  calcilicationj. 

On  microscopic  examination  of  the  wall  of  the  aneurysm  it  has  been 
noticed  that  the  elastic  hiyer  of  the  media  has  disappeared,  and  some 
physicians  have  considered  this  the  primary  cause  for  the  dilatation  of  the 

vessel. 

Htiology. — As  arteriosclerotic  alterations  predispose  to  the 
formation  of  aneurysms,  it  will  not  occasion  surprise  that  most 


Fig.  9. — Dulness  yielded  by  an  aneurysm  of  the  ascendin"-  aorta :  1,  increased  area  of 
cardiac  dulness  :  2,  aneurysmal  dulness;  from  a  photograph  (personal  observation,  Zurich 
clinic}. 

oases  of  aneurysm  occur  in  advanced  life,  thus  beyond  the  fortieth 
year.  Presenile  arteriosclerosis  and  aneurysmal  formation  early 
in  life  may,  however,  lie  induced  by  special  injurious  influences, 
among  which  syphilis,  alcoholism,  gout,  obesity,  physical  over-exer- 
tion, and  traumatism  may  be  included.  Men  suifer  more  commonly 
than  women  from  aneurysm  of  the  aorta,  ,by  reason  of  the  nature 
of  the  causative  factors.  In  some  countries  aneurysms  occur  with 
especial  fref|uencv,  for  instance,  in  England.  This  probably  de- 
pends mainly  upon  the  extent  to  which  alcoholism  and  syphilis 
prevail. 


ANEURYSM  OF  THE  AORTA 


67 


Symptoms. — The  existence  of  aneurysm  of  the  aorta  is  some- 
times indicated  only  by  suspicious  sjnnptoms.  These  include  ob- 
stinate neuralgia  in  the  course  of  the  nerves  of  the  arm  or  the 
intercostal  nerves,  difficulty  in  swallowing  in  consequence  of  con- 
striction of  the  esophagus,  epigastric  pain,  and  severe  vomiting — all 
manifestations  dependent  upon  pressure  exerted  by  the  aneurysm 
upon  contiguous  nerves  or  upon  the  esophagus  or  the  stomach. 
1  ascular  murmurs  over  the  manubriimi  sterni  or  in  the  course 
of  the  vertebral  column  are  also  noteworth}^  and  suspicious  signs. 


Fig.  10.— Aneurysm  of  the  rlescendins  aorta,  after  destruction  of  the  ribs  lying  immedi- 
ately beneath  the  skin  ;  from  a  photograph  (personal  observation,  Zurich  cliuic). 


A  positive  diagnosis  may  be  ventured  upon  when  certain  local 
alterations  in  the  circulatory  apparatus  are  demonstrable.  The 
most  frequent  of  these  are  abnormal  areas  of  dulness,  prominences, 
pulsation,  and  murmurs.  Aneurysm  of  the  ascending  aorta  and 
of  the  arch  of  the  aorta  are  usually  attended  with  dulness  over 
the  manubrium  sterni  and  the  adjacent  chest- wall,  so  that  a  second 
area  of  dulness  is  superimposed  upon  the  area  of  cardiac  dulness 
(Fig.  9).  Aneurysm  of  the  descending  aorta  gives  rise  to  dulness 
to  the  left  of  the  vertebral  column.  Naturally,  the  dulness  does 
not  correspond  to  the  entire  extent  of  the  aneurysm,  but  only  to 


68  CIRCULATORY  ORGANS 

that  portion  applied  to  tlic  cliest-wall.  Xot  rarely  the  area  of 
dulness  projects  above  the  level  of  the  adjacent  surface.  The 
aneurysm  may  even  have  caused  disappearance  of  bony  portions 
of  the  thorax  by  pressure,  and  become  both  palpable  and  visible 
as  a  pulsating  tunior  directly  beneath  the  skin  (p,  67,  Fig.  10). 
Protrusion  and  pulsation  may  be  detected  with  especial  distinctness 
when  viewed  with  lateral  illumination.  At  times  the  aneurysm 
exhibits  more  violent  pidsation  than  the  heart,  and  an  appearance 
is  created  of  two  distinct  pulsating  bodies  functionating  in  the 
thorax  independently  of  each  other.  It  may  be  of  importance 
to  introduce  the  index-finger  from  the  jugular  fossa  behind  the 
sternimi,  and  to  push  it  downward,  when  an  aneurysm  of  the 
ascending  aorta  or  of  the  arch  of  the  aorta  is  present,  because  in 
this  way  the  dilated  and  pulsating  vessel  can  be  reached  with  the 
tip  of  the  finger.  >Systolic  murmurs  are  usually  audible  over 
aneurysms  of  the  aorta,  for  the  sudden  dilatation  of  the  lilood- 
stream  gives  rise  to  blood-whirls  within  the  aneurysm.  Murmurs 
will  be  wanting  only  when  the  aneurysm  is  so  thoroughly  filled 
with  thromtii  that  dilatation  of  the  blood-channel  is  no  longer 
present. 

Not  rarely  a  systolic  and  a  diastolic  murmur  are  audible  over  aortic 
aneurysms.  The  diastolic  murmur  is  either  generated  within  the  aneurysm 
itself,  when  the  diastolic  reflux  of  the  blood  takes  place  with  such  energy 
that  audible  blood-whirls  occur  within  the  aneurysm,  or  transmitted  from 
the  aortic  valve  (which  has  frequently  at  the  same  time  become  incompe- 
tent in  consequence  of  arteriosclerosis)  to  the  aneurysm.  Under  the  latter 
condition  the  acoustic  character  of  the  diastolic  murmur  over  the  aortic 
valve  and  over  the  aneurysm  is  the  same. 

Aneurysms  of  the  ascending  aorta  and  of  the  arch  of  the  aorta 
usually  give  rise  to  displacement  of  the  heart  downward  and  out- 
ward, so  that  the  apex-beat  is  found  outside  the  left  mammillary 
line  and  lower  than  the  left  fifth  intercostal  space.  Generally 
there  is  hypertrophy  of  the  left  ventricle  (heaving  apex-beat) ;  which 
some  observers,  however,  attribute  to  the  aortic  valvular  insuf- 
ficiency as  a  rule  present  at  the  same  time.  In  cases  of  pure 
aortic  aneurysm  atrophy  of  the  heart  is  said  to  take  place  in  con- 
sequence of  deficient  nutrition  of  the  lienrt-muscle. 

The  character  of  the  pulse  is  further  worthy  of  consideration 
in  cases  of  aortic  aneurysm  ;  it  varies  in  accordance  with  the  seat 
of  the  aneurysm.  In  cases  of  aneurysm  of  the  ascending  aorta 
all  of  the  peripheral  pulses  appear  belated,  as  compared  with  the 
apex-beat  of  the  heart,  because  the  blood  is  restrained  within  the 
aneurysm.  Aneurysms  of  the  arcli  of  the  aorta  permit  the  pulse 
to  appear  synchronously  in  the  right  radial  and  the  carotid  with 
the  apex-beat,  while  the  pulse  in  the  left  carotid,  the  left  radial, 
and  the  femoral  arteries  is  belated  when  the  aneurysm  is  situated 
between  the  point  of  origin  of  the  innominate  and  the  left  carotid. 


ANEURYSM  OF  THE  AORTA  69 

If,  however,  the  aneurysm  is  situated  between  the  left  carotid  and 
the  left  subclavian,  the  right  radial  pulse  and  the  two  carotid 
pulses  occur  synchronously  with  the  apex-beat,  while  the  left 
radial  and  the  femoral,  on  the  other  hand,  appear  later.  In  cases 
of  aneurysm  of  the  descending  aorta,  finally  the  pulse  in  the  neck 
and  in  the  arms  is  palpable  synchronously  with  the  apex-beat^ 
while  it  occurs  later  in  the  femoral  arteries. 

Eetardatiou  of  the  pulse  can  take  place  in  cases  of  aortic  aneurysm 
only  in  consequence  of  constriction  and  distortion  of  the  orifices  of  vessels 
arising  close  to  the  aneurysm  ;  but  under  such  conditions  the  retarded  pulse 
is  further  characterized  by  deficient  fulness. 

Subjective  discomfort  may  be  wanting  throughout  the  whole 
course  of  the  disease ;  but,  as  a  rule,  the  patients  complain  of  dis- 
tressing beating,  a  sense  of  constricton  and  pain  in  the  chest. 
Attacks  of  palpitation  of  the  heart  and  dyspnea  also  not  rarely 
occur. 

Every  aneurysm  has  a  tendency  to  increase  in  size,  and  this 
may  be  a  source  of  two  dangers,  namely,  excessive  pressure  upon 
adjacent  organs  and  rupture  of  the  aneurysm.  The  pressure- 
phenomena  vary  in  accordance  with  the  seat  and  the  direction  of 
growth  of  the  aneurysm.  Aneurysms  of  the  ascending  aorta  and 
of  the  aortic  arch  frequently  give  rise  to  unilateral  or  bilateral 
paralysis  of  the  recurrent  laryngeal  nerve.  Obstinate  and  severe 
eervicobracMal  neuralgia  is  also  not  rarely  observed.  If  motor 
nerves  suffer  in  consequence  of  the  pressure,  pareses  and  paralyses 
appear  in  the  arm  (principally  the  left).  Aneurysms  of  the 
descending  aorta  often  give  rise  to  the  most  distressing  intercostal 
lumbo-abdominal  neuralgia.  They  also  frequently  cause  a  pain- 
ful sense  of  stiffness  in  the  vertebral  column,  so  that  patients  are 
capable  of  moving  about  only  with  difficulty  in  a  position  bent 
forward.  At  times  a  bronchus  is  compressed.  Math  the  develop- 
ment of  the  clinical  picture  of  bronchostenosis  (usually  left-sided); 
or  pressure  on  the  esophagus  gives  rise  to  stenosis  of  that  tube, 
with  the  danger  of  death  from  starvation.  Even  the  bones  are 
unable  to  resist  the  advance  of  an  aneurysm.  By  erosion  of 
the  bony  portion  of  the  chest-wall  the  aneurysm  may  come  to  lie 
beneath  the  external  integument.  In  other  instances  articular 
attachments  are  severed.  Even  the  vertebral  column  is  at  times 
perforated  by  an  aneurysm,  with  resulting  compression  of  the 
spinal  cord  and  spinal  paralysis ;  or  the  aneurysm  ruptures  and 
discharges  its  bloody  contents  into  the  vertebral  canal. 

Rupture  of  an  aneurysm  is  favored  by  excessive  physical  and 
mental  activity,  which  increase  the  blood-pressure ;  but  it  may 
occur  also  during  complete  rest  and  during  sleep.  At  times  rup- 
ture takes  place  outward  through  the  skin.  Sometimes,  after  pre- 
vious discoloration,  the  skin  ruptures  at  several  points,  the  blood 
at  first  trickling  but  slowly,  so  that  at  the  beginning  it  may  be 


70  CIRCULATORY  ORGANS 

possible  to  control  the  hemorrhage ;  but  at  other  times  a  great  tear 
suddenly  takes  place  in  the  skin,  through  Avhich  the  patient"  bleeds 
to  death  witiiin  a  few  seconds.  Bnpture  info  tJte  pericardial  cavity 
not  rarely  takes  place,  the  pericardium  rapidly  filling  with  blood, 
and  sudden  death  occurs  in  consequence  of  cardiac  paralysis. 
Rupture  into  one  of  the  pleural  cavities  takes  place  still  more  fre- 
quently, and  with  especial  frequency  into  the  left  pleural  cavity. 
Rupiture  into  the  esophagus,  the  bronchi,  and  the  trachea  has  als(» 
been  observed.  Less  conmionly  rupture  takes  place  into  the  cavi- 
ties of  the  heart  or  into  the  vence  cava'.  Aneurysms  of  the  descend- 
ing aorta  at  times  give  rise  to  undermining  and  detachment  of  the 
pleura  or  the  peritoneum  through  the  extravasated  blood. 

The  duration  of  an  aneu7'ysm  does  not,  as  a  rule,  extend  beyond 
a  year  and  a  half,  although  observations  are  on  record  covering  a 
period  of  more  than  twenty  years. 

The  termination  is  usually  fatal,  death  occurring  from  rupture 
of  the  aneurysm  or  in  consequence  of  pressure-disturbances  (steno- 
sis of  the  esophagus,  spinal  paralysis),  or  from  progressive  maras- 
mus, or  at  times  also  from  embolism  derived  from  detached 
thrombi.  It  should  be  mentioned  that  pidmonary  tubercidosis  is 
not  rare  in  association  with  aortic  aneurysm. 

Diagnosis. — The  recognition  of  aneurysm  of  the  aorta  is  not 
rarely  attended  with  considerable  difficulty,  even  in  cases  in  which 
the  symptoms  are  not  exclusively  suspicious.  In  the  presence  of 
pulsating  tumors  care  should  be  taken  to  avoid  confusion  with  solid 
tumors  situated  upon  the  aorta,  and  receiving  transmitted  move- 
ment from  it.  Under  the  latter  conditions,  however,  only  eleva- 
tion and  depression  take  jilace,  but  not  expansile  pulsation  of  the 
swelling.  The  location  of  an  aneurysm  will  be  indicated  by  the 
situation  of  the  dulness,  the  tumor  and  the  pulsation  that  may  be 
present,  and  the  character  of  the  pulse  as  previously  pointed  out. 

Prognosis. — The  cure  of  an  aneurysm  through  abundant 
thrombus-formation  and  obliteration  of  the  sac  can  scarcely  be 
hoped  for,  and  almost  without  exception  death  from  rupture  or 
exhaustion,  or  one  of  the  complications  already  mentioned,  is  to  be 
feared  within  a  short  time.     The  prognosis  is  thus  unfavorable. 

Treatment. — Individuals  suffering  from  aneurysms  of  the 
aorta  must  ol)serve  permanently  bodily  and  mental  rest,  and  avoid 
all  irritating  articles  of  diet  (strong  coffee,  tea,  alcohol).  A  daily 
movement  of  the  bowels  should  be  secured,  as  expulsive  efforts  may 
cause  rupture  of  the  aneurysm. 

Fasting  has  properly  been  abandoned  as  a  means  of  treatment,  because 
it  hastens  the  loss  of  strength  already  taking  place. 

Rest  in  bed  for  months,  the  constant  ajiplication  of  an  ice-bag, 
daily  applications  of  iodoform-collodion,  and  the  internal  adminis- 
tration of  potassium  iodid  can  be  warmlv  recommended  : 


CONSTRICTION  AND   OCCLUSION  OF  THE  AORTA  71 

K     Iodoform,  1.0  (15  grains) ; 

Collodion,  10.0  (2^  fluidrams).— M. 

Apply  topically. 

R    Solution  of  potassium  iodid,  {  ^^  gi^fluidluncesr ' 

Dose :  1  tablespoonful  thrice  daily. 

Not  much  can  be  expected  from  astringents  (plumbic  acetate,  tannic  acid, 
ergot,  solution  of  ferric  chlorid). 

Surgical  treatment  has  been  variously  recommended  for  aortic 
aneurysm,  especially  the  introduction  of  gold  needles  connected 
with  the  positive  pole  of  a  galvanic  current,  so  called  electro- 
puncture,  or  the  introduction  of  foreign  bodies  (watch-spring, 
horsehair,  silk  thread  ^),  in  order  to  induce  coagulation  within  the 
sac.  Injections  of  solution  of  fei'ric  chlorid  are  probably  not  free 
from  danger  of  embolism. 

Subcutaneous  injections  of  100  or  200  c.c.  of  physiologic  salt- 
solution  containing  one  or  two  per  cent,  of  white  gelatin  have  also 
been  employed  with  advantage. — A.  A.  E. 

Ligation  of  the  right  subclavian  and  carotid  has  been  proposed 
in  the  treatment  of  aneurysm  of  the  arch  of  the  aorta.  Among 
individual  conspicuous  symptoms  severe  neuralgia  especially  re- 
quires often  the  frequent  employment  of  morphin  subcutaneously. 

CONSTRICTION  AND  OCCLUSION  OF  THE  ISTHMUS 
OF  THE  AORTA  (ISTHMUS  AORTAE  PERSISTENS). 

The  junction  of  the  arch  of  the  aorta  with  the  descending 
aorta,  where  the  duct  of  Botal  enters  into  the  aorta,  is  known  as 
the  isthmus  of  the  aorta.  In  newborn  children  a  constriction  of 
the  lumen  of  the  aorta  exists  at  this  point,  and  which  gradually 
disappears.  Under  some  conditions  the  constriction  may  persist, 
or  the  aorta  may  even  become  closed.  The  distribution  of  blood 
to  and  the  nutrition  of  the  lower  half  of  the  body  can  then  be 
effected  only  through  the  collateral  paths  that  arise  from  the  aorta 
above  the  isthmus,  and  anastomose  with  arteries  that  arise  from 
the  aorta  below  the  isthmus.  These  collateral  channels,  which 
are  scarcely  ever  seen  in  healthy  persons,  become  tortuous,  pul- 
sating, and  vibrating  vessels  distended  to  the  size  of  a  finger,  and 
over  which,  frequently,  also  cardiac-systolic  murmurs  can  be 
heard.  This  is  an  important  and  distinctive  diagnostic  phenom- 
enon. The  following  principal  collateral  paths  may  be  men- 
tioned : 

1.  Subclavian  artery,  internal  mammary  artery,  anterior  inter- 
costal arteries  and  superior  intercostal  artery,  posterior  intercostal 
arteries,  thoracic  aorta. 

^  Success  has  also  attended  the  introduction  of  long  coils  of  gold  wire  through 
which  a  galvanic  current  is  passed. — A.  A.  E. 


72  CIRCULATORY  ORGANS 

2.  Subclavian  artery,  transverse  artery  of  the  neck,  dorsal 
artery  of  the  scapula,  posterior  intercostal  arteries,  thoracic  aorta. 

3.  Subclavian  artery,  transverse  scapular  artery,  subscapular 
arteries,  posterior  intercostal  arteries,  thoracic  aorta. 

4.  Subclavian  artery,  internal  mammary  artery,  superior  epi- 
gastric artery,  inferior  epigastric  artery,  iliac  artery. 

The  character  of  the  femoral  j)ulse  is  noteworthy,  being  greatly 
retarded  in  comparison  with  the  apex-beat  of  the  heart,  and  being 
further  characterized  by  its  slight  fulness.  The  left  ventricle 
undergoes  dilatation  and  hypertrophy  in  consequence  of  the  re- 
duction in  the  aortic  blood-current,  and  frequently  death  has  been 
observed  to  take  place  from  rupture  of  the  heart  or  cerebral  hem- 
orrhage. In  other  instances  paralysis  of  the  heart  takes  place 
gradually,  with  weakness  of  the  myocardium  and  general  venous 
stasis.  Patients  may,  hoAvever,  attain  great  age.  Nothing  is 
known  as  to  the  causes  of  the  condition.  About  one  hundred 
cases  have  thus  far  been  reported.  The  treatment  is  confined  to 
the  relief  of  prominent  symptoms. 


EMBOLISM  OF  THE  AORTA. 

Emboli  in  the  aorta  are  mostly  derived  from  detached  thrombi 
and  vegetations  on  the  aortic  or  mitral  valves,  less  commonly 
from  cardiac  thrombi  in  the  left  ventricle  or  from  perforating 
tumors  or  echinococcus-cysts  of  the  heart.  Thrombi  in  aneu- 
rysms or  upon  arteriosclerotic  lesions  in  the  aorta  may  also  become 
detached  and  be  swept  into  the  aorta  as  emboli.  If  the  orifice  of 
the  aorta  be  occluded  by  an  embolus,  sudden  death  occurs,  because 
the  supply  of  blood  to  the  heart-muscle  and  to  the  brain  ceases. 
Frequently  emboli  reach  the  point  of  bifurcation  of  the  aorta, 
upon  which  they  ride,  sending  branches  into  both  common  iliac 
arteries.  The  patients  then  complain  mostly  of  sudden  pain  in 
the  lower  extremity  with  the  lodgment  of  the  embolus.  The 
femoral  pulse  is  wanting,  and  the  extremities  appear  pale  and 
feel  cold  like  those  of  a  corpse.  The  function  of  the  sensory  and 
motor  nerves  is  abolished,  with  the  development  of  anesthesia  and 
motor  palsy  in  the  e.vtremities.  If  an  adequate  collateral  circula- 
tion do  not  develop  promptly,  gangrene  of  the  extremities  takes 
place,  and  the  patients  die  in  consequence  of  septicemia.  From  a 
therapeutic  point  of  view  the  physician  is  powerless  in  the  face 
of  such  conditions. 


PART  II. 

DISEASES  OF  THE  RESPIRATORY 
ORGANS. 


I.    DISEASES    OF    THE    NOSE. 


NASAL  CATARRH    (CATARRHAL  RHINITIS), 

Ktiology. — Catarrhal  inflammation  of  the  nasal  mucous 
membrane,  also  designated  coryza,  is  a  most  ividespread  disease. 
Although  every  person  is  probably  attacked  by  coryza  more  than 
once  during  his  life,  it  appears  that  the  tendency  to  suffer  from 
this  disorder  is  a  variable  one.  Delicate,  pale,  and  slightly  built 
persons  are  attacked  by  coryza  with  especial  frequency  and  readi- 
ness. Scrofulous  persons,  also,  are  in  marked  degree  susceptible 
to  the  disorder,  and  likewise  persons  who  are  exposed  to  the 
inhalation  of  dust  and  irritating  gases.  Among  the  causative 
factors  infectious,  toxic,  and  traumcdic  (mechaniccU)  influences  may 
be  especially  mentioned  ;  to  these  may  be  added  extension  of  con- 
tiguous inflammcdion. 

Infectious  rhinitis  may  occur  either  as  an  independent  and 
'primary  disease,  or  as  a  secondary  disorder  in  the  sequence  of 
other  infectious  diseases,  such  as  influenza,  measles,  typhoid  fever. 
Primary  infectious  rhinitis  is  often  attributed  to  exposure  to  cold ; 
but  even  though  it  be  conceded  that  coryza  may  quickly  follow 
such  exposure,  this,  in  all  probability,  acts  only  as  a  contributing 
influence,  lowering  the  resistance  of  the  tissues  and  affording 
better  opportunity  for  the  invasion  and  propagation  of  lower 
forms  of  organisms  capable  of  exciting  inflammation  (bacteria) 
by  inducing  changes  in  the  circulation  in  the  nasal  mucous  mem- 
brane. It  is  true  that  nothing  positive  is  yet  known  as  to  the 
nature  of  these  bacteria.  Bacteriologic  examinations  have  dis- 
closed the  presence  of  bacteria  in  the  nasal  secretion,  but  as  a 
matter  of  course  nothing  is  thereby  demonstrated,  as  bacteria  can 
also  be  found  in  the  nasal  mucus  of  healthy  persons,  being  taken 
up  from  the  inspired  air  by  the  moist  mucous  membrane.  There 
seems  scarcely  any  doubt  that  coryza  possesses  a  considerable 

73 


74  REsriUATony  organs 

degree  of  contagiousnesH,  and  among  careful  laymen  it  is,  there- 
fore, a  rule  not  to  kiss  any  one  suffering  from  the  disorder. 

Toxic  rhiiiiti.^  may  l)e  induced  by  agents  taken  internally,  thus 
through  the  l)lood,  or  by  the  inhahition  of  irritating  gases.  It 
is  well  known  tliat  coryza  may  result  from  the  ingestion  of  potas- 
sium iodid  or  potassium  bromid.  It  may  likew'ise  follow  inhala- 
tion of  tiie  vapors  of  hydrochloric  acid,  nitric  acid,  chlorin-gas, 
and  the  like. 

TrauiiKiiic  (niechanicd/)  rhinitis  is  at  times  a  result  of  the  inha- 
lation of  dust,  and  therefore  occurs  frequently  as  an  occupation 
nasal  catarrh.  Foreign  bodies  that  have  penetrated  the  nares  also 
frequently  give  rise  to  rhinitis.  Those  who  indulge  in  snuff  often 
suffer  from  catarrhal  rhinitis,  this  substance,  irritating  the  nasal 
mucous  memljrane  in  part  mechanically,  in  part  chemically. 

At  times  catarrhal  rhinitis  arises  by  extension  from  adjacent 
disease,  and  it  may  occur,  for  instance,  in  association  with  ab- 
scesses of  the  gums. 

Symptoms,  Diagnosis,  Anatomic  Alterations,  and 
Prognosis. — A  distinction  is  made  between  acute  and  chronic 
catarrhal  rhinitis  in  accordance  with  the  duration  and  the  course 
of  an  attack  of  coryza.  In  many  cases  acute  coryza  begins  like 
and  pursues  the  course  of  an  acute  infectious  disease.  The  patients 
frequently  at  first  feel  languid  for  hours,  and  even  for  days,  as  if 
worn  out,  and  they  not  rarely  fear  the  onset  of  some  serious  dis- 
order. Chilliness  and  febrile  movement  give  added  justification 
for  anxiety.  Soon,  however,  local  alterations  in  the  nose  make 
their  appearance.  A  burning  and  prickling  sensation  becomes 
appreciable  in  one  nasal  passage,  or  in  both.  The  nares  become 
impassable  to  the  current  of  air,  and  speech  acquires  a  nasal 
quality.  In  a  short  time  a  tendency  to  frequent  sneezing  becomes 
manifest,  and  finally  an  unusually  active  secretion  takes  place 
from  the  nasal  mucous  membrane,  so  that  in  the  course  of  a  day 
a  large  number  of  handkerchiefs  are  soiled.  The  nasal  secretion 
is  at  first  thin,  like  water,  colorless,  and  of  a  salty  taste ;  after  a 
while  it  becomes  less  abundant,  more  viscid,  and  greenish  and 
purulent,  because  round  cells  in  large  number  have  become  added 
to  the  secretion  originally  deficient  in  cellular  elements.  If  the 
upper  lip  is  moistened  by  the  nasal  secretion,  slight  redness  and 
swelling  of  the  skin  develop.  In  the  course  of  a  few  days  the 
manifestations  described  usually  begin  to  disappear,  and  in  some 
a  feeling  of  almost  remarkable  freshness  sets  in. 

The  anatomic  alterations  can  be  best  followed  with  the  aid  of 
a  nasal  mirror  during  life.  ^Marked  redness  and  swelling  of  the 
nasal  mucous  membrau(\  accumulations  of  mucus  and  pus,  and 
here  and  there  also  small  hemorrhages  can  be  ol>served. 

Complications  occur  especially  through  extension  of  the  inflam- 
mation to  adjacent  mucous  membranes.     Pain  on  either  side  of  the 


NASAL  CATARRH  75 

root  of  the  nose,  often  severe  and  distressing,  is  dependent  upon 
niflammation  of  the  mucous  membrane  of  the  frontal  sinuses. 
Painful  sensations  in  the  upper  jaw  indicate  involvement  of  the 
antrum  of  Highmore.  Marked  lacrimation  and  active  redness 
and  swelling  of  the  conjunctiva  indicate  that  the  inflammation 
has  attacked  the  lacrimal  duct  and  the  conjunctiva.  Catarrh  of 
the  mucous  membrane  of  the  Eustachian  tube  (tinnitus  aurinm, 
impairment  of  hearing),  and  especially  inflammation  of  the  middle 
ear,  constitute  unpleasant  accidents.  Catarrh  of  the  mucous  mem- 
brane of  the  pharynx,  larynx,  trachea,  and  bronchi  is  not  rarely 
superadded  to  that  of  the  nasal  mucous  membrane. 

Chronic  catarrh  of  the  nasal  mucous  membrane  frequently  de- 
velops from  repeated  attacks  of  acute  nasal  catarrh,  especially  if 
recurrence  takes  place  before  the  preceding  attack  has  been  cured. 
In  other  instances,  however,  chronic  coryza  appears  in  its  chronic 
form  from  the  outset.  The  result  depends  in  part  upon  the  causa- 
tive factors.  Patients  with  chronic  coryza  suffer  from  impermea- 
bility of  the  nares,  so  that  they  are  compelled  to  breathe  with  the 
mouth  open.  As  a  result  the  facial  expression  acquires  a  stupid 
appearance,  and  the  deficient  warming  of  the  inspired  air  predis- 
poses to  inflammatory  afiPections  of  the  upper  air-passages.  The 
sense  of  smell,  and,  in  connection  therewith,  the  sense  of  taste 
appear  impaired.  Speech  becomes  nasal.  Usually  purulent  se- 
cretion i^s  formed  in  excessive  amount,  which  in  part  dries  upon 
the  mucous  membrane  as  grayish-green  crusts  and  mussel-like 
deposits,  and  often  can  be  expelled  only  with  great  difficulty  by 
blowing  the  nose.  At  times  the  inflamed  nasal  mucous  membrane 
secretes  an  abundance  of  thin  fluid,  and  this  condition  has  been 
designated  rhinorrhea. 

On  rhinoscopic  examination  it  is  found  that  a  distinction  must 
be  made  between  hypertrophic  and  atrophic  chronic  nasal  catarrh. 
In  the  presence  of  chronic  hypertrophic  catarrhal  rhinitis  the  nasal 
mucous  membrane  appears  thrown  into  folds  and  thickened,  so 
that  the  nasal  passages  are  constricted.  The  mucous  membrane 
is  grayish  or  brownish-red  in  color,  and  widely  dilated  and  tortuous 
blood-vessels  are  often  visible  upon  it.  In  addition  there  are  pres- 
ent considerable  deposits  of  mucus  and  pus  and  desiccated  grayish- 
green  crusts.  Chronic  atrophic  catarrhal  rhinitis  may  develop  from 
the  hypertrophic  variety,  but  appears  to  occur  also  as  an  inde- 
pendent affection.  The  nasal  mucous  membrane  is  characterized 
by  pallor  and  attenuation,  so  that  the  nasal  cavity  is  noteworthy 
for  its  unusual  roominess.  Microscopic  examination  of  the  nasal 
mucous  membrane  discloses  absence  of  erectile  tissue,  collection 
of  round  cells  in  the  subepithelial  layer  of  the  mucous  membrane, 
and  transformation  of  the  ciliated  epithelium  into  squamous  epi- 
thelium, whicli  in  part  is  cornified.  Experience  has  shown  that 
chronic    atrophic    rhinitis    develops    especially    in    persons    with 


76  RESPIRATORY  ORGANS 

broad,  depressed  nasal  bridges,  and  that  in  some  families  it  is 
hereditary. 

Chronic  coryza  may  be  attended  with  various  complications, 
of  which  ozena  is  especially  annoying.  Often  this  is  a  sequel  of 
atrophic  rhinitis,  while  in  other  instances  ulcers  have  formed  upon 
the  nasal  mucous  membrane,  and  have  extended  from  this  to  the 
bony  substructure,  and  thus  maintain  an  offensive  nasal  discharge. 
It  is,  therefore,  customary  to  make  a  distinction  between  simple 
ozena  and  ulcerative  ozena.  Xot  rarely  the  inflamed  nasal  mucous 
membrane  undergoes  hyperplasia  and  nasal  polypi  develop.  At 
times  reflex  neuroses  arise,  and  these  have  been  observed  with 
especial  frequency  in  association  with  hypertrophic  catarrh.  Among 
such  reflex  neuroses  bronchial  asthma,  ocular  diseases,  psychic  dis- 
turbances, even  deformities  of  the  thorax,  scoliosis,  and  a  tendency 
to  abortion  have  been  described,  although  some  of  the  statements 
must  be  received  with  a  certain  amount  of  skepticism.  Unpleasant 
complications  may  arise  from  extension  of  the  chronic  i njlarnmatary 
process  from  the  nose  to  contiguous  mucous  membranes.  Among 
these  may  be  mentioned  chronic  inflammation  of  the  frontal  sinuses, 
the  antra  of  Highmore,  the  ear,  and  the  pharynx.  Although 
chronic  coryza  is  a  disorder  scarcely  dangerous  to  life,  it  is  never- 
theless a  most  obstinate  and  a  trying  disease. 

Treatment. — Prophylactic  measures  may  be  employed  in  the 
case  of  delicate  persons  and  those  exposed  to  the  inhalation  of 
dust  and  irritant  gases.  In  an  attack  of  acute  febrile  coryza 
recumbency  in  bed  should  be  recommended,  with  the  ingestion 
of  hot  infusions  (pectoral  species,  elder-flowers,  linden-flowers — a 
tablespoonful  to  two  cups  of  hot  water).  In  addition,  inhala- 
tions of  hot  steam  afford  great  relief.  Attempts  have  been  made 
to  abort  acute  coryza,  and  for  this  purpose  the  following  formula 
of  Hagen-Brandt  has  a  certain  reputation  : 

R  Carbolic  acid,  5.0  (75  grains); 

Alcohol,  15.0  (.}  fluidounce) ; 

"Water  of  ammonia,  6.0  (75  minims); 

Distilled  water,  16.0  (4  fluidrams).— M. 

Keep  in  a  dark  bottle  with  a  glass  stopper. 
Dose :  A  few  drops  poured  upon  three  or  four  sheets  of  thick  bibulous 
paper,  and  inhaled  every  two  hours,  with  the  eyes  closed,  so  long  as  an  odor 
is  appreciable. 

Severe  frontal  pain  is  best  relieved  by  means  of  salicylic  acid, 
sodium  salicylate,  or  phenacetin  (1.0 — 15  grains — thrice  daily).  In 
the  treatment  of  chronic  coryza  various  snuffs  and  irrigations  (nasal 
douche)  have  been  employed.  Astringents  and  disinfectants  have 
been  recommended  for  the  latter  purpose.  I  prescribe  irrigation 
of  the  nares,  morning  and  evening,  with  carbolic  acid  (2.0  :  200) 
or  solution  of  aluminum  acetate  (2.0  :  200),  and  then  insuflflation 
into  the  nose  of  a  small  amount  of  the  following  powder : 


HA  Y-FEVER  77 

R  Mercurous  chlorid,  3.0  (45  grains) ; 

Alum,  5.0  (75      "     ).— M. 

Use  as  a  snufF. 

In  the  treatment  of  hypertrophic  rhinitis  the  galvanocautery 
is  used  a  good  deal.  Crusts  can  be  removed  by  repeated  injec- 
tions of  hikewarm  solution  of  sodium  chlorid  (1.5  :  200).  In  the 
treatment  of  ozena  I  have  observed  the  best  results  from  the  use 
of  iodoform  as  a  snuff,  while  internally  potassium  iodid  (5.0  :  200 
— a  tablespoonful  thrice  daily)  may  be  employed.  Ulcers  should 
be  cauterized  with  silver  nitrate.  Change  of  residence  not  rarely 
exerts  a  favorable  influence  in  cases  of  chronic  coryza  ;  for  instance, 
a  sojourn  by  the  sea. 

FIBRINOUS  INFLAMMATION  OF  THE  NASAL  MUCOUS 
MEMBRANE  (FIBRINOUS  RHINITIS)  ♦ 

Fibrinous  inflammation  of  the  nasal  mucous  membrane  is  rare. 
It  is  attended  with  the  formation  of  fibrinous  membranes  upon 
the  surface  of  the  nasal  mucous  membrane,  and  which  can  be 
detached  without  loss  of  substance.  Among  the  causative  factors 
are  especially  chemic  and  infectious  agencies.  The  disorder  may 
thus  occur  at  times  in  consequence  of  cauterization  of  the  nasal 
mucous  membrane.  In  some  instances  it  is  excited  by  diphtheria- 
hacilli,  which  usually  find  lodgment  upon  the  nasal  mucous 
membrane  in  the  sequence  of  pharyngeal  diphtheria,  and  rarely 
independently,  and  give  rise  to  nasal  diphtheria.  It  is  probable, 
however,  that  a  number  of  other  as  yet  but  little  known  bacteria 
are  capable  of"  giving  rise  to  fibrinous  inflammation  of  the  nasal 
mucous  membrane.  This  is  true  especially  of  those  cases  in  which 
the  condition  develops  in  conjimction  with  other  infectious  diseases 
(measles,  scarlet  fever,  typhoid  fever,  fibrinous  pneumonia). 

The  symptoms  consist  in  obstruction  of  the  nares  and  in 
nasal  discharge,  which  may  acquire  a  putrid  character. 

The  diagnosis  is  easy  when  fibrinous  membranes  are  extruded 
or  are  visible  on  rhinoscopic  examination. 

The  treatment  consists  in  irrigation  of  the  nose  with  carbolic 
acid  (from  1.0  to  4.0  :  100),  mercuric  chlorid  (1.0  :  100),  or  lime- 
water. 

HAY- FEVER   (AUTUMNAL  CATARRH). 

il^tiology. — Hay-fever  is  known  also  as  Bostock's  catarrh, 
because  it  was  first  thoroughly  described  by  Bostock  in  1819.  It 
occurs  either  as  a  severe  catarrh  of  the  nasal  mucous  membrane, 
or  as  asthma,  or  as  a  mixed  form.  It  is  attributed  to  inhalation 
of  the  pollen  of  the  G-ramineae,  as  pollen-grains  have  been  found 
in  the  nasal  and  lacrimal  secretions  of  patients.  In  support  of  the 
etiologic  significance  of  the  pollen  of  plants  is  the  fact  that  the 


78  RESPIRATORY  ORGANS 

manifestations  of  hay-fever  appear  just  at  the  time  when  grasses 
and  irniins  are  in  bloom,  and  that  many  are  only  attacked  in  pass- 
inu'  a  l)l()()niing-  meadow  or  a  Lrraiii-tield.  Nevertiieless  a  certain 
predisposition  to  the  disease  exists,  ■which  is  to  he  sought  for  in 
an  acquired  or  conoccnital,  or  even  inherited,  neuropathic  state. 
Accordinjilv,  individuals  in  the  higher  walks  of  life  are  attacked 
(cultured  persons,  menrhants)  most  frequently.  The  disease  is 
especially  prevalent  in  America,  where  the  neuropathic  state  is 
quite  common.  Within  a  few  years  it  has  appeared  to  me  that 
the  disease  is  gradually  l^eeomiug  more  common  among  us. 

Symptoms  and  Diagnosis. — Xot  rarely  the  symptoms  of 
hay-fever  develop  immediately  in  the  sequence  of  preceding  injury, 
and  some  are  attacked  by  the  disease  whenever  they  inadvertently 
come  into  proximity  with  a  blooming  meadow,  or  perhaps  in  going 
about  are  compelled  to  pass  a  hay-Avagon.  Uay-cori/za  is  mani- 
fested by  a  sense  of  prickling,  of  burning,  and  of  a  foreign  body 
in  the  nose.  The  patients  sneeze  frequently,  and  are  unable  to 
obtain  air  through  the  nose.  Speech  becomes  nasal.  In  a  short 
while  an  abundant,  watery,  salty  nasal  discharge  sets  in.  Exten- 
sion of  the  nasal  catarrh  to  the  lacrimal  canal  and  the  conjunctiva 
is  attended  with  profuse  secretion  of  tears,  and  with  redness  and 
swelling  of  the  conjunctiva.  At  times  the  tegumentary  covering 
of  the  nose  becomes  deeply  reddened.  Many  patients  suffer  from 
.severe  frontal  headache  in  consequence  of  catarrh  of  the  frontal 
sinuses,  and  are  as  a  result  incapacitated  from  work.  At  times 
chilliness  and  slight  febrile  movement  are  present.  The  disorder 
may  persist  for  weeks,  during  the  entire  period  that  the  Graminese 
are  in  bloom,  and  it  is  further  characterized  by  the  unpleasant  fact 
that  it  habitually  recurs  whenever  opportunity  is  afforded  for  the 
inhalation  of  pollen.  Hay-asthmfi  entirely  resembles  ordinary 
bronchial  asthma,  and  accordingly  manifests  itself  in  attacks  of 
shortness  of  breath,  attended  with  expiratory  dyspnea  especially, 
and  loud  snoring  and  whistling  rales.  Pollen  has  been  found  in 
the  sputum,  in  addition  to  asthma-crystals.  In  the  mixed  forms 
of  hay-fever  the  disease  most  frequently  begins  as  a  corvza,  with 
which  asthma  subsequently  becomes  associated. 

Prognosis. — Hay-fever,  although  not  dangerous  to  life,  is  a 
most  obstinate  disease,  and  not  rarely  renders  its  victims  incap- 
able of  pursuing  their  vocation  for  weeks. 

Treatment. — The  treatment  should  in  the  first  place  be  pro- 
phylactic. An  existing  neurotic  state  should  be  attacked  by  the 
]irescription  of  a  sensible  mode  of  life,  by  means  of  cold-water 
treatment,  residence  at  the  seaside,  and  nervines.  Hay-fever  has 
frequently  been  found  in  association  with  al)normal  distensibility 
of  the  nasal  mucous  membrane,  and  cauterization  of  this  mem- 
brane has,  therefore,  been  recommended.  In  addition,  the  patients 
must  avoid  exposure  to  inhalation  of  pollen,  and  often  for  this 


CATARRH  OF  THE  LARYNX  79 

reason  they  must  change  their  residence.  I  have  observed  good 
results  in  the  treatment  of  hay-coryza  from  the  use  of  a  snuff  of 
calomel  and  alum : 

JR     Calomel, 

Alum,  each  3.0  (45  grains) ; 

Morphin  hydrochlorate,  0.3  (4i       "     ).— M. 

Use  thrice  daily  as  a  snufl'. 

Irrigation  of  the  nose  with  a  solution  of  quinin  has  also  been 
praised  (1.0  :  740).  Hay-asthma  may  be  most  certainly  relieved 
by  means  of  narcotics ;  for  instance,  by  a  subcutaneous  injection 
of  morphin. 

MYCOSIS  NASL 

In  isolated  cases  molds  {Aspergillus),  filamentous  fungi  {Botrytis 
Bassiana),  and  budding  fungi  [O'idium  albicans,  thrush  fungus)  have 
been  found  upon  the  nasal  mucous  membrane,  and  yellowish-gray 
or  greenish  fungous  masses  in  the  nasal  discharge.  In  treatment 
irrigation  Avith  carbolic  acid  (from  1.0  to  5.0  :  200),  mercuric 
chlorid  (1.0 :  1000)  and  insufflation  of  boric  acid  may  be  practised. 


II.    DISEASES   OF  THE   LARYNX. 


CATARRH  OF  THE  LARYNX  (CATARRHAL 
LARYNGITIS), 

Ktiology. — Catarrh  of  the  laryngeal  mucous  membrane  is  one 
of  the  most  widespread  diseases.  Delicate,  anemic,  and  debili- 
tated individuals  are  especially  predisposed  to  the  affection.  The 
causes  are  almost  the  same  as  those  responsible  for  nasal  and  bron- 
chial catarrh.  A  distinction  must  be  made  here  also  between 
infectious,  chemic,  thermic,  and  traumatic  (mechanical)  causes,  to 
Avhich  may  be  added  laryngeal  catarrh  by  extension  from  adjacent 
disease,  and  hypostaiic  catarrh. 

Infectious  catarrh  of  the  larynx  may  be  primary  or  secondary. 
Secondary  catarrh  develops  in  the  sequence  of  other  preceding 
disease ;  for  instance,  whooping-cough,  measles,  influenza,  pulmo- 
nary tuberculosis,  syphilis.  Primary  infectious  catarrh  of  the 
larynx  is  also  variously  known  as  rheumatic  or  refrigeratory,  as 
formerly  it  Avas  attributed  to  the  influence  of  cold  (rheuma). 
While  this  influence  in  the  development  of  laryngeal  catarrh 
cannot  be  denied,  and  although  this  is  observed  to  occur  with 
especial  frequency  in  northern  and  rugged  regions,  and  in  the 
spring  and  autumn  at  the  time  of  variations  in  the  weather,  the 
influence  of  cold  appears  to  be  confined  to  the  circumstance  that 


80  RESPIRATORY  ORGANS 

the  lower  teraperatufe  provides  favorable  conditions  for  the  inva- 
sion of  certain  bacteria,  through  altered  blood-distribution  and 
diminished  powers  of  resistance,  whereas  the  actual  excitants  of 
the  disease  are  bacteria  with  their  toxins.  Accurate  information 
as  to  the  nature  of  these  Ijacteria  is,  it  is  true,  as  yet  wanting.  In 
harmony  with  the  infectious  nature  of  the  catarrhal  conditions 
of  the  larynx  under  consideration  is  the  fact  that  the  disease,  like 
many  other  infectious  diseases,  not  rarely  occurs  in  epidemic  dis- 
tribution. Infectious  laryngeal  catarrh  must  further  be  included 
amono^  those  infectious  diseases  that  leave  a  marked  tendencv  to 
repeated  attacks. 

Laryngeal  catarrh  due  to  cheniic  injiuences  may  result  from  in- 
halation of  irritating  gases  (vapors  of  hydrochloric  or  nitric  acid 
or  of  chlorin)  or  develop  after  the  ingestion  of  certain  substances, 
among  which  potassium  iodic!  and  potassium  bromid  are  the  best 
known.  In  the  latter  event  the  substances  are  eliminated  from 
the  blood  through  the  laryngeal  mucous  membrane,  in  which  they 
excite  inflammation.  Laryngeal  catarrh  is  a  common  manifesta- 
tion in  alcoholics.  Perhaps  cheraic  influences  are  operative  in  the 
production  of  the  laryngeal  catarrh  of  patients  sufiering  from  renal 
disease. 

Among  the  thermic  causes  of  laryngeal  catarrh  is  inhalation  of 
hot  vapors. 

Laryngeal  catarrh  due  to  traumatic  {mechanical)  injiuences  is 
frequently  au  occupation-catarrh,  and  accordingly  of  chronic  nature. 
Prolonged  speaking,  singing,  or  commanding  is  a  common  cause 
of  chronic  catarrh  of  the  larynx  in  teachers,  ministers,  actors, 
public  speakers,  singers,  and  officers.  In  other  individuals  catarrh 
of  the  larynx  results  from  the  inhalation  of  dust  and  smoke  (mil- 
lers, glovers,  stone-cutters,  smokers). 

Ilypostatic  catarrh  of  the  larynx  develops  in  conjunction  with 
chronic  disease  of  the  heart  and  of  the  respiratory  organs,  when 
the  flow  of  blood  from  the  vente  cava;  to  the  right  auricle  is  inter- 
fered with,  because  the  action  of  the  right  ventricle  is  thereby 
impaired  and  all  of  the  blood  is  not  sent  into  the  pulmonary  artery 
with  each  systole. 

Laryngeal  catarrh  by  extension  from  adjacent  disease  is  at  times 
secondary  to  similar  disease  of  the  nose  or  of  the  pharynx  above, 
or  of  the  bronchi  and  the  trachea  below. 

Symptoms,  Anatomic  Alterations,  and  Diagnosis. — 
The  symptoms  of  catarrh  of  the  larynx  require  especial  consid- 
eration, accordingly  as  the  condition  is  acute  or  chronic.  Acute 
catarrh  of  the  larynx  not  rarely  pursues  the  course  of  a  febrile, 
infectious  disease,  with  initial  chill  and  fever.  In  other  instances 
elevation  of  temperature  is  wanting.  In  diagnosis  the  local  alter- 
ations are  naturally  the  most  significant.  The  patients  usually 
complain  first  of  a  sense  of  tickling  and  of  irritation  in  the  larynx. 


CATARRH  OF  THE  LARYNX  81 

The  congli  is  often  especially  annoying  toward  evening  and  during 
the  night,  and  thus  disturbs  sleep.  At  first  a  small  amount  of 
viscid,  transparent  mucus  is  expectorated  with  difficulty  (sputum 
crudiuii).  Only  after  some  time  does  the  expectoration  become 
more  abundant  and  looser — that  is,  more  readily  ejected — opaque, 
and  greenish-yellow  (sputum  coccum).  If  the  vocal  bands  are 
involved  in  the  catarrhal  process,  the  voice  is  changed,  becom- 
ing veiled,  impure,  and  in  marked  cases  completely  toneless. 
The  reason  for  this  resides  most  frequently  in  the  fact  that  the 
inflamed  and  thickened  vocal  bands  are  no  longer  capable  of 
coming  in  accurate  approximation  during  speech. 

The  anatomic  alterations  attending  acute  catarrh  of  the  larynx 
may  be  most  accurately  studied  with  the  aid  of  the  laryngoscope^ 
much  more  accurately  than  on  the  cadaver,  because  after  death 
the  alterations  (hyperemia,  swelling)  may  have  receded  to  a  con- 
siderable degree.  The  inflamed  parts  are  characterized  by  exces- 
sive distention  with  blood,  and  correspondingly  appear  abnormally 
reddened.  Here  and  there  an  isolated  tortuous  and  distended 
blood-vessel  can  be  recognized.  Besides,  the  inflamed  areas  are 
swollen.  The  secretion  of  the  mucous  membrane  is  also  greatly 
increased,  and  raucous  and  purulent  deposits  are  often  seen  upon 
the  surface  of  the  mucous  membrane.  IVot  rarely  these  have 
formed  between  the  vocal  bands,  so  that  long  strands  of  mucus 
and  pus  are  visible  in  this  situation  in  phonation.  At  times  the 
distention  of  the  mucous  membrane  with  blood  is  so  great  that 
vessels  rupture  and  the  interior  of  the  larynx  is  covered  with  free 
blood.  If  this  be  removed  with  a  camel's-hair  brush,  under  the 
guidance  of  the  laryngoscope,  it  rapidly  reaccuraulates  at  times. 
The  expectoration  is  at  the  same  time  bloody,  and  the  patients  are 
thrown  into  a  great  state  of  alarm  by  the  fear  of  pulmonary  tuber- 
culosis, of  which  they  consider  the  expectoration  of  blood  a  certain 
precursor.  This  variety  of  laryngeal  catarrh  has  been  designated 
hemorrhagic  laryngitis.  At  times  the  epithelial  layer  of  the  laryn- 
geal mucous  membrane  is  exfoliated  in  places,  with  the  develop- 
ment of  catarrhal  erosions  and  ulcers. 

In  some  cases  the  inflammatory  exudation  extends  to  the 
laryngeal  muscles,  with  the  development  of  paralysis  of  individual 
muscles.  Most  frequently  the  arytenoid  and  the  internal  thvro- 
arytenoid  are  affected  (gaping  of  the  posterior  third  of  the  chink 
of  the  glottis — cartilaginous  glottis — in  the  first,  and  of  the 
anterior  two-thirds — ligamentous  glottis — in  the  latter  case  in 
phonation. 

In  children  signs  of  laryngeal  stenosis  appear  suddenly  at 
times,  and  disappear  within  a  short  time.  As  the  symptoms 
resemble  those  of  laryngeal  diphtheria  or  of  croup,  the  con- 
dition has  been  designated  pseudocroup.  The  children  often  are 
awakened  during  the  night  with  a  cry  that  they  are  suffocating. 


82  RESPIRATORY  ORGANS 

Respiration  is  labored ;  inspiration  is  stridulous ;  the  face  presents 
an  expression  of  fear  and  is  cyanotic ;  inspiratory  retraction  of 
tlie  intercostal  spaces  is  visible ;  and  the  signs  of  embarrassed 
brcatiiin«:  are  evident.  In  tiie  course  of  a  few  hoars  the  threaten- 
ing numifestations  usually  subside,  but  they  may  be  repeated  on 
succeeding  nights.  The  condition  is  distinguished  from  laryngeal 
diphtheria  by  the  absence  on  laryngoscopic  examination  of  diph- 
theric deposits  in  the  larynx,  disappearance  spontaneously  as  a  rule 
of  the  danger  of  suffocation,  and  the  possible  repetition  of  the 
paroxysm  a  number  of  times.  The  symptoms  of  pseudocroup  may 
be  induced  by  various  diseases,  especially  by  marked  SM'elling  of 
individual  laryngeal  structures  (false  vocal  bands,  interarytenoid 
fold,  mucous  membrane  below  the  true  vocal  bands),  paresis  of 
individual  laryngeal  muscles,  or  accumulation  of  mucus  above  the 
true  vocal  bands,  with  adhesion  of  these  structures.  Pseudocroup 
is  rare  in  adults  because,  as  compared  with  children,  the  larynx  is 
much  more  commodious. 

Acute  laryngeal  catarrh  usually  terminates  within  a  few  days, 
and  but  rarely  lasts  longer  than  two  weeks. 

CJironie  catarrh  of  the  larynx  either  occurs  as  an  independent 
affection  or  it  develops  in  the  sequence  of  a  preceding  acute 
catarrh,  when  this  has  recurred  a  number  of  times,  particularly 
if  the  recurrences  set  in  before  the  previous  acute  attack  has  ended. 
Certain  causes  (occupational  influences,  stasis,  pulmonary  tubercu- 
losis, nephritis)  are  especially  calculated  to  give  rise  to  chronic 
catarrh  of  the  larynx.  Chronic  laryngeal  catarrh  is  luiattended 
Avith  febrile  movement  unless  an  acute  exacerbation  of  a  chronic 
inflammatory  condition  takes  place.  A  sense  of  irritation,  of  tick- 
ling, and  of  the  presence  of  a  foreign  body  in  the  region  of  the 
larynx,  and  a  rough  and  hoarse  voice  are  the  principal  symptoms. 
Examination  with  the  laryngoscope  discloses  not  a  bright-red  or 
rose-red  appearance,  but  rather  a  brownish-red  color  of  the  laryn- 
geal mucous  membrane.  The  thickening  of  the  mucous  memlirane 
depends  less  upon  infiltration  with  fluid  than  u])on  an  inflammatory 
hyperplasia  of  the  mucosa  and  submucosa.  In  addition  there  is 
increased  secretion  of  mucus.  In  cases  of  chronic  laryngeal  catarrh 
also  catarrhal  erosions  and  ulcers  may  form.  At  times  there 
develop,  especially  on  the  true  vocal  bands,  proliferations  and 
thickenings  of  the  epithelium  in  the  form  of  warts.  A  similar 
condition  is  observed  especially  in  persons  compelled  to  strain  the 
laryngeal  structures  (singers,  speakers),  and  it  has  been  designated 
pacht/dcrmia  of  the  larynx.  In  singers  and  speakers  nodules  form 
also  at  the  free  margin  of  the  vocal  bands,  in  consequence  of 
connective-tissue  hyperplasia,  so-called  singers'  vocJes.  Active 
hyperplasia  of  the  follicles  of  the  mucous  membrane  causes  the 
interior  of  the  larynx  to  present  a  gramdar  surface — r/ranular 
laryngitis.     If  the  true  vocal  bands  especially  are  nodular,  the 


CATARRH  OF  THE  LARYNX  83 

condition  is  designated  tuberous  cliorditis.  Circumscribed  hyper- 
plasia of  the  laryngeal  mucous  membrane  leads  to  the  formation 
of  pendulous  tumors,  laryngeal  polypi  and  papillomata.  At  times 
the  mucous  membrane  of  the  inferior  surface  of  the  true  vocal 
bands  is  involved  in  active  hyperplasia  {chorditis  vocalis  hyper- 
trophlca  inferior),  and  the  mucous  membrane  beneath  the  vocal 
bands  can  be  seen  to  project  toward  the  median  line  like  a  fish- 
bladder,  and  constrict  the  chink  of  the  glottis.  Should  the  hyper- 
plasia become  excessive,  suffocation  may  result  from  stenosis  of 
the  chink  of  the  glottis.  Some  clinicians  consider  syphilis  as  the 
cause  of  these  alterations.  Paralysis  of  the  laryngeal  muscles  also 
not  rarely  takes  place  in  conjunction  with  chronic  catarrh  of  the 
larynx.  Chronic  laryngeal  catarrh  is  a  troublesome  affection, 
which  sometimes  never  disappears.  It  interferes  with  the  pursuit 
of  one's  vocation,  and  may  compel  the  adoption  of  another. 

Prognosis. — The  prognosis  of  acute  catarrh  of  the  larynx 
is  almost  always  favorable.  Chronic  catarrh  of  the  larynx  also 
rarely  endangers  life,  but  recovery  can  only  be  hoped  for  when 
the  causes  of  the  disorder  can  be  permanently  removed.  Occu- 
pational catarrhs  are  frequently  attended  with  insurmountable 
difficulties. 

Treatment. — Certain  prophylactic  measures  should  not  be 
overlooked  by  the  careful  clinician.  These  include  intelligent 
hardening  and  the  avoidance  of  inhalation  of  dust  and  vapors 
and  of  excessively  loud  and  long-continued  speaking  and  singing. 
In  cases  of  acute  catarrh  of  the  larynx  rest  in  bed  is  to  be  advised 
when  fever  is  present.  In  addition  hot  infusions  may  be  adminis- 
tered (pectoral  species,  elder-flowers,  linden-flowers,  one  table- 
spoonful  to  two  cups  of  hot  water)  and  a  narcotic  prescribed  for 
the  laryngeal  irritation  ;  for  instance  : 

R     Bitter-almond  water,  10.0  (2J  fluidrams) ; 

Morphin  hydrochlorate,  0.1  (li  grains). — M. 

Dose :  10  drops  for  laryngeal  irritation. 

Or, 

R     Morphin  hydrochlorate,  0.003  (-^  grain)  ; 

Sugar,  0.3  (4J  grains).— M. 

Make  10  such  powders. 
Dose :  1  powder  for  laryngeal  irritation. 
Or, 

R     Powder  of  ipecacuanha  and  opium, 

Sugar,  each  0.3  (4|  grains).— M, 

Make  10  such  powders. 
Dose:  1  powder  for  laryngeal  irritation. 
Or, 

R     Potassium  bromid,  1.0    ( 15  grains); 

Morphin  hydrochlorate,  0.02  (^  grain). — M. 

Sugar  and  tragacanth  sufficient  to  make  10  troches. 
Dose :  1  troche  every  hour  or  two. 


84  RESPIRATORY  ORGANS 

As  long  as  the  inflamed  laryngeal  nmcous  membrane  secretes 
viscid  mneiis  inhalations  of  alkalies  by  means  of  Siegle's  appa- 
ratus (sodimn  chlorid,  from  1.0  to  5.0:100;  sodium  bicarbon- 
ate, from  1.0  to  5.0:100;  sodium  carbonate,  from  1.0  to  5.0: 
100;  potassium  bromid,  from  1.0  to  3.0:100)  may  be  recom- 
mended at  intervals  of  two  hours.  AVhen  the  secretion  subse- 
quently becomes  more  abundant  and  more  diffluent,  the  alkalies 
should  be  replaced  bv  astringents  (argentic  nitrate,  from  0.1  to 
1.0:100;  tannic  acid,  from  1.0  to  3.0:100;  alum,  from  1.0 
to  3.0:100;  solution  of  aluminum  acetate,  from  0.3  to  1.0: 
lOOj.  In  cases  of  hemorrhagic  laryngitis  inhalations  of  solution 
of  ferric  chlorid  (from  0.1  to  0.3  :  100)  should  be  employed. 
When  symptoms  of  pseudocroup  arise  the  fears  of  the  patient 
should  be  allayed  by  gentle  encouragement.  In  addition  deriva- 
tives should  be  applied  to  the  skin  of  the  neck  (alcoholic  frictions, 
sponges  dipped  in  warm  water).  Should  the  shortness  of  breath 
increase  in  a  noteworthy  degree  an  emetic  should  be  administered 
(solution  of  copper  sulphate,  1.0  :  100 — a  dessertspoonful  every 
ten  minutes  until  vomiting  is  induced  ;  or  solution  of  apomorphin 
hydrochlorate,  0.2  :  10.0 — one-quarter  of  a  hypodermic  syringe- 
ful  subcutaneously).  Only  rarely  will  it  be  necessary  to  resort 
to  intubation  or  tracheotomy. 

Chronic  laryngeal  catarrh  is  usually  treated  locally  by  means 
of  inhalations,  applications,  or  insufflations.  In  the  employment  of 
any  of  these  measures  the  rule  should  be  observed  to  change  the 
medicament  after  the  lapse  of  a  few  days,  as  the  mucous  mem- 
brane readily  becomes  accustomed  to  the  remedy,  and  then  no 
longer  reacts  thereto.  In  practising  the  procedures  named,  astrin- 
gents are  employed,  although  it  is  advisable  to  use  stronger  solu- 
tions than  in  the  treatment  of  acute  laryngeal  catarrh.  For 
insufflation  into  the  larynx  tannic  acid  (0.1 — 1^  grains),  plumbic 
acetate  (0.05 — -|  grain),  or  alum  (0.1 — 1-t  grains)  is  employed.  At 
times  it  is  necessary  to  institute  causative  treatment,  and,  for  in- 
stance, in  cases  of  syphilis  to  employ  preparations  of  iodin  and 
mercury,  or  in  the  presence  of  hypostatic  catarrh  digitalis  and 
other  heart-tonics.  Those  who  can  afford  it  will  do  well  in  the 
presence  of  obstinate  chronic  catarrh  of  the  larynx  to  take  a  course 
of  treatment  during  the  summer  at  a  bathing-resort.  The  alkaline- 
chlorin  springs  (Ems,  Selters,  Wiesbaden,  Gleichenberg),  saline 
baths  (Soden,  Reichenhall,  Baden-Baden,  Ischl),  sulphur-springs 
(Neundorf,  Weilbach,  Stachelberg,  Baden  near  Vienna,  Baden  in 
Switzerland.  Schinznach,  Mehadia,  Eaux  Bonnes),  and  earthy 
springs  (Lippspringe,  Weissenburg),  deserve  especial  consideration 
in  this  connection. 

Ulcers  of  the  larynx  should  be  cauterized  with  the  stick  of 
silver  nitrate,  while  laryngeal  polypi  and  pajjillomata  should  be 
removed    by   operative    measures.     In   cases  of  chorditis  vocalis 


EDEMA   OF  THE  GLOTTIS  85 

hypertrophica  inferior  an  endeavor  should  be  made  to  cause  the 
disappearance  of  the  hyperplasia  by  means  of  potassium  iodid 
(5.0  :  200,  a  tablespoonful  thrice  daily),  and  when  the  dyspnea 
attains  threatening  proportions  intubation  or  tracheotomy  should 
be  practised.  Dilatation  of  the  chink  of  the  glottis  l)y  means  of 
sounds  also  has  been  attempted.  I  have  effected  a  cure  in  a 
number  of  cases  of  obstinate  chronic  laryngeal  catarrh  in  the 
treatment  of  which  all  possible  remedies  had  previously  been 
employed  without  result  by  means  of  inhalations  of  compressed  air 
and  faradization  of  the  larynx. 

EDEMA  OF  THE  GLOTTIS, 

Anatomic  Alterations. — Edema  of  the  glottis  consists  in 
infiltration  of  the  submucous  tissue  of  the  larynx  with  transuda- 
tion or  exudation.  Accordingly,  a  distinction  is  made  between 
hydropic  and  inflammatory  edema  of  the  glottis.  In  cases  of  in- 
flammatory edema  of  the  glottis  the  fluid  poured  out  into  the 
submucosa  may  be  serous,  seropurulent,  purulent,  and  in  rare 
cases  even  bloody.  A  circumscribed  accumulation  of  pus  is 
designated  an  abscess  of  the  larynx.  The  diseased  laryngeal 
structures  are  conspicuous  for  their  great  increase  in  volume,  and 
if  they  be  punctured  fluid  usually  escapes,  when  the  mucous  mem- 
brane covering  the  previously  swollen  structures  becomes  wrin- 
kled and  collapsed.  Further,  the  swelling  has  not  rarely  sub- 
sided in  the  cadaver.  In  cases  of  hydropic  edema  of  the  glottis 
the  mucous  membrane  often  presents  an  exceedingly  anemic  hue, 
while  in  cases  of  inflammatory  edema,  on  the  other  hand,  the 
mucous  membrane  may  be  deeply  reddened,  although  here  also 
a  paler  hue  is  present  when  the  accumulated  fluid  has  made  the 
blood-vessels  of  the  mucous  membrane  empty  through  pressure. 
Edema  of  the  glottis  is  usually  best  developed  upon  the  epiglottis 
and  the  aryepiglottic  folds,  because  in  these  situations  the  sub- 
mucosa is  looser  and  provided  with  a  more  abundant  network. 
The  structures  named  are  often  converted  into  distorted  swellings 
as  thick  as  a  finger,  which  obstruct  the  entrance  into  the  larynx. 
Accordingly,  the  false  vocal  bands  and  the  region  of  the  aryte- 
noid cartilages  are  with  especial  frequency  the  seat  of  edematous 
swelling. 

^l^tiologfy. — Hydropic  edema,  of  the  glottis  develops  with  espe- 
cial frequency  in  the  course  of  cachectic  diseases  and  of  conditions . 
of  stasis,  of  which  nephritis,  pulmonary  tuberculosis,  carcinoma, 
and  chronic  diseases  of  the  heart  and  lungs  may  be  mentiohed  as 
examples.  At  times  local  causes  of  stasis  are  present  in  the  veins 
of  the  laryngeal  mucous  membrane  (goiter,  enlargement  of  lymph- 
atic glands,  mediastinal  tumors,  aortic  aneurysm),  and  under  such 
conditions  the  edema  of  the  glottis  may  be  unilateral  and  circum- 


S6  RESPIRATORY  ORGANS 

scribed.  Inflammatory  edema  of  the  r/lottis  occurs  most  frequently 
in  association  with  disease  of  the  larynx,  as,  for  instance,  after 
inrtanunation,  ulceration,  in  association  witli  larvngeal  perichon- 
dritis, after  inhahition  of  hot  vapors,  irritating  gases,  dust,  after 
injuries  of  the  larvnx,  and  after  the  inspiration  of  foreign  bodies. 
At  times  tlie  disorder  develops  in  the  sequence  of  infectious  dis- 
eases, among  which  typhoid  fever,  pneumonia,  and  erysipelas  may 
be  mentioned.  It  occurs  at  times  as  a  collateral  edema  in  cases  of 
parotiditis,  angina,  and  angina  Ludovici. 

Rarely  edema  of  the  glottis  is  of  angioneurotic  origin,  developing  in 
conjunction  with  angioneurotic  edema  of  the  skin  and  of  the  jiharyux. 

Occasionally  edema  of  the  glottis  has  been  observed  to  occur 
without  demonstrable  cause — ><po)itan.eous  edema  of  the  (/lottia, 
although  in  some  cases  the  condition  may  have  been  erysipelas  of 
the  laryngeal  mucous  membrane.  Experience  has  taught  that 
edema  of  the  glottis  occurs  more  frequently  in  men  than  in  women  : 
and  adults  are  more  commonly  affected  than  children. 

Symptoms. — The  manifestations  of  edema  of  the  glottis  con- 
sist in  the  signs  of  stenosis  of  the  larynx.  Breathing  is  visibly 
embarrassed  aud  inspiration  especially  appears  interfered  icith  and 
prolonged.  Inspiration  takes  place  with  a  certain  degree  of  cau- 
tion in  order  to  avoid  aspiration  of  the  tumid  parts,  and  thus  com- 
plete exclusion  of  air.  It  is  usually  stridulous,  and  occasions 
diminution  in  the  total  number  of  respirations.  During  each  inspi- 
ration the  larynx  and  the  trachea  are  actively  drairn,  downward. 
The  nasal  ahe  dilate  in  advance  of  inspiration,  and  the  mouth  is 
opened,  gasping  for  air  to  a  certain  degree.  The  auxiliary 
muscles  of  respiration,  in  the  neck  especially  the  sternomastoid, 
contract  vigorously  during  inspiration,  while  the  intercostal  muscles 
are  depressed,  bi^cause  the  lungs  are  only  imperfectly  filled  with 
air  and  distended  duriug  inspiration.  The  voice  is  feeble  and  not 
rarely  almost  toneless.  The  patients  assume  an  orthopneic  position 
of  the  body,  are  usually  intensely  cyanotic,  and  exhibit  an  anxious 
expression  of  the  flice.  The  forehead  is  covered  with  cold  sweat. 
The  pulse  becomes  small  and  frequent,  but  often  retains  a  fair 
degree  of  tension.  The  skin  feels  cool.  If  the  dyspnea  become 
excessive,  consciousness  is  graduallv  lost  and  death  often  occurs 
amid  muscular  twitchings.  In  accordance  with  the  duration  and 
course  a  distinction  is  made  between  acute,  subacute,  and  chronic 
edema  of  the  glottis.  Acute  edema  of  the  glottis  persists  at  times 
for  scarcely  an  hour,  whereas  chr(^nic  edema  may  be  protracted  for 
days  and  weeks.  In  the  latter  event  ago:ravation  and  improve- 
ment not  rarely  alteruate  with  each  other. 

Diagnosis. — While  the  recognition  of  stenosis  of  the  larynx 
is  not  dilHcult,  difficulties  may  arise  in  the  way  of  correctly  refer- 
ring the  condition  to  edema  of  the  o-lottis.     Examination  with  the 


PERICHONDRITIS  OF  THE  LARYNX  87 

laryngoscope  would  naturally  lead  readily  to  a  correct  decision,  but 
it  is  by  no  means  easy  to  examine  in  this  way  persons  suffering 
from  intense  dyspnea.  Not  rarely  the  thickened  laryngeal  struc- 
tures can  be  felt  with  the  finger  introduced  through  the  mouth  in 
the  direction  of  the  orifice  of  the  larynx.  The  history  also  must 
receive  careful  consideration. 

Prognosis. — The  prognosis  of  edema  of  the  glottis  is  under 
all  conditions  most  serious,  in  view  of  the  danger  of  death  from 
suffocation,  which  often  takes  place  with  surprising  rapidity. 

Treatment. — If  in  a  case  of  edema  of  the  glottis  the  dysp- 
nea has  become  alarming,  relief  can  be  expected  only  from  opera- 
tive intervention  (intubation  or  tracheotomy),  and  Avhen  demanded 
by  necessity  the  best  instruments  at  hand  must  be  employed  (a  pen- 
knife to  open  the  trachea,  a  hollow  pen-holder  or  a  quill  instead 
of  a  tracheal  cannula).  It  has  further  been  suggested  that  the 
edematous  mucous  membrane  be  scarified  with  a  curved  bistoury 
wrapjied  with  strips  of  adhesive  plaster,  except  at  its  free  ex- 
tremity, and  the  fluid  be  evacuated,  or  even  that  the  raucous  mem- 
brane be  lacerated  with  a  sharpened  finger-nail,  but  at  the  present 
day  such  suggestions  are  purely  theoretic.  Under  less  alarming 
conditions  attempts  have  been  made  to  dissipate  the  edema  of  the 
glottis  by  means  of  derivatives  (hot  sponges,  leeches,  counter-irri- 
tant applications  to  the  skin  of  the  neck)  and  of  emetics  or  purga- 
tives. 

INFLAMMATION  OF  THE  PERICHONDRIUM  OF  THE 
LARYNX  (PERICHONDRITIS  OF  THE  LARYNX). 

Ktiologfy. — Inflammation  of  the  perichondrium  of  the  larynx 
is  usually  a  secondary  disorder,  occurring  in  conjunction  with  inflam- 
mation and  ulceration  of  various  kinds  within  the  interior  of  the 
larynx.  Catarrhal,  tuberculous,  syphilitic,  carcinomatous,  typhoid 
ulceration,  ulceration  following  smallpox  and  cholera,  may  all  give 
rise  to  the  disease.  The  affection  at  times  occurs  as  a  primary  dis- 
order after  injury  of  the  larynx.  The  patients  are  usually  adults, 
whereas  the  disease  is  uncommon  in  children. 

Anatomic  Alterations. — Perichondritis  of  the  larynx  leads 
to  an  accumulation  of  pus  between  the  perichondrium  and  the  car- 
tilages of  the  larynx.  At  times  the  cartilage  is  completely  sur- 
rounded by  pus,  and  is  exfoliated  when  rupture  of  the  pus  takes 
place.  The  pus  at  times  acquires  a  fetid  odor,  while  the  necrotic 
cartilage  appears  calcified,  fibrillated,  or  cornified.  If  the  abscess- 
cavity  closes  and  cicatrization  takes  place,  deformity  and  stenosis 
of  the  larynx  may  result.  The  larynx  also  at  times  undergoes 
collapse.  Most  frequently  the  disease  involves  the  arytenoid  car- 
tilages, and  least  commonly  the  epiglottis. 

iSymptoms  and  Diagnosis. — Perichondritis  of  the  larynx 


88  RESPIRATORY  ORGANS 

can  be  recognized  with  certainty  only  with  the  aid  of  the  laryngo- 
scope, the  seat  of  the  disease  being  marked  by  an  intumescence, 
which  not  rarely  presents  the  appearance  of  pus  through  the  mucous 
membrane  and  fluctuates  on  ])alpatiou  with  the  sound.  Purulent, 
and  often  fetid,  expectoration  containing  fragments  of  cartilage 
would  be  suggestive  of  ])erichondritis.  Hoarseness  and  pain  in  the 
region  of  the  larynx  are  too  equivocal  as  symptoms  to  l)e  available 
for  diagnostic  purposes.  Pain  of  especial  severity  usually  attends 
the  intjestion  of  food  and  fluid  when  the  arvtenoid  cartilasres  or  the 
epiglottis  is  the  seat  of  perichondritis.  Many  patients  refuse  food 
and  fluid,  and  prefer  to  run  the  risk  of  starvation.  Perichondritis 
of  the  larynx  may  be  followed  by  various  consequences.  The 
formation  of  a  considerable  amount  of  pus  may  cause  such  reduc- 
tion in  the  cavity  of  the  larynx  as  to  give  rise  to  danger  of  death 
from  suffocation.  Suffijcation  may  also  occur  from  rupture  of  the 
accumulation  of  pus  into  the  larynx  during  sleep  or  from  impacted 
or  exfoliated  fragments  of  cartilage  in  the  larynx.  Death  from 
suffocation  may  also  occur  as  a  result  of  edema  of  the  glottis,  which 
may  be  superadded  to  perichondritis  of  the  larynx.  Not  rarely 
perichondritis  of  the  larynx  gives  rise  to  a  febrile  state,  in  which 
alarming  loss  of  strength  may  take  place.  As  may  be  understood, 
this  danger  is  the  greater  when  the  patient  refuses  to  take  food  on 
account  of  the  pain.  At  times  the  pus  from  the  ruptured  abscess 
enters  the  deeper  air-passages,  and  gives  rise  to  aspiration-pneu- 
monia, or  pulmonary  abscess  or  gangrene.  The  pus  also  at  times 
finds  its  way  beneath  the  skin  of  the  neck,  where  it  gives  rise  to 
inflammation  or  to  erosion  of  the  large  vessels  of  the  neck,  with 
fatal  hemorrhage.  At  times  rupture  of  pus  takes  place  simulta- 
neously into  the  larynx  and  into  the  esophagus,  or  into  the  larynx 
and  beneath  the  skin  of  the  neck,  with  the  development  of  an 
internal  or  an  external  laryngeal  fistida.  Even  when  the  morbid 
process  has  healed  certain  dangers  2ixv(\.  seqneke  remain.  Cicatricial 
deformity  and  angulation  of  the  larynx  readily  give  rise  to  stenosis 
or  to  persistent  hornseness. 

Prognosis. — The  prognosis  in  cases  of  perichondritis  of  the 
larynx  is  always  serious,  as  the  disorder  is  painful  and  not  unat- 
tended with  danger. 

Treatment. — Causal  treatment  is  ]n'<^bably  applicable  only  in 
cases  of  sv])hilis  miercurv,  potassium  iodid).  Xot  rarely  surgical 
intervention  is  required  (incision  of  abscesses,  removal  of  exfoli- 
ating fragments  of  cartilaire).  It  is  often  necessary  to  relieve  pain, 
and  for  this  purpose  applications  of  cocain  (1.0  :  10)  may  be  espe- 
cially recommended.  If  the  expectoration  is  offensive,  inhalation 
of  disinfectants  (carbolic  acid,  2.0:100;  solution  of  aluminum 
acetate,  1.0  :  100)  may  be  prescribed.  Danger  of  suffocation 
demands  tracheotomv.  In  cases  of  extensive  perichondritis  of 
the  larynx  even  extirpation  of  the  larynx  has  been  proposed. 


PARALYSIS  OF  THE  MUSCLES  OF  THE  LARYNX  89 

PARALYSIS  OF  THE  MUSCLES  OF  THE  LARYNX. 

Ktiology. — Paralysis  of  the  muscles  of  the  larynx  is  caused 
either  by  disease  of  the  related  nerve  or  by  changes  in  the  mus- 
cular structure,  and  acc(jrding;ly  a  distinction  has  been  made 
between  neurogenous  and  myogenous  paralysis.  It  is  not  always 
possible  to  decide  with  certainty  as  to  the  origin  of  a  given  paral- 
ysis. K^eurogenous  paralysis  of  the  muscles  may  be  of  central, 
peripheral,  or  mixed  (reflex)  origin.  Central  paralysis  occurs  espe- 
cially in  association  with  disease  of  the  jjons  Varolii  and  the  medulla 
oblongata,  when  the  centers  for  the  laryngeal  nerves  in  this 
situation  are  involved  in  the  morbid  process.  Such  paralysis  is 
observed  also  in  cases  of  acute  and  chronic  bulbar  paralysis,  mul- 
tiple sclerosis,  and  tabes  dorsalis.  In  cases  of  ordinary  cerebral 
hemiplegia  also  paralysis  of  the  laryngeal  muscles  upon  the  para- 
lyzed side  is  frequently  present.  Hysteria  is  a  frequent  cause  for 
paralysis  of  the  muscles  of  the  larynx.  The  condition  is  unat- 
tended with  anatomic  alterations,  and  constitutes  a  so-called  func- 
tional paralysis.  Paralysis  of  the  muscles  of  the  larynx  is  often 
associated  with  disease  of  the  vagus,  and  especially  pressure-paral- 
ysis of  this  origin  is  not  rare.  Thus,  paralysis  of  the  laryngeal 
muscles  is  not  uncommonly  observed  in  conjunction  with  tumors 
of  the  neck  (enlarged  lymphatic  glands,  goiter),  with  mediastinal 
tumors,  aneurysms  of  the  aorta,  pleurisy,  pericarditis,  carcinoma 
of  the  esophagus.  Enlarged  bronchial  glands  and  contraction  of 
the  lung  also  at  times  cause  paralysis  of  the  recurrent  laryngeal 
nerve.  At  times  the  vagus  is  divided  in  the  neck  in  the  course 
of  operative  removal  of  goiter,  and  paralysis  of  the  laryngeal 
muscles  results.  Whether  the  toxic  and  infectious  paralyses  of  the 
muscles  of  the  larynx  are  of  central  or  of  peripheral  origin  is  un- 
decided. They  have  been  observed  in  connection  with  lead- 
poisoning,  pharyngeal  diphtheria,  typhoid  fever,  and  the  like. 
Reflex  paralysis  of  the  muscles  of  the  larynx  has  been  observed  to 
occur  in  association  with  disease  of  the  tonsils,  with  the  presence 
of  worms  in  the  intestine,  and  with  uterine  disease,  and  to  dis- 
appear quicivly  after  correction  of  the  primary  disorder.  Myogen- 
ous paralysis  of  the  muscles  of  the  larynx  occurs  especially  in  the 
sequence  of  other  diseases  of  the  larynx,  thus  after  severe  catarrh, 
and  in  association  with  edema  of  the  glottis  and  perichondritis. 
Straining  of  the  vocal  bands  in  singing  or  in  speaking  may  be 
followed  by  paralysis  of  the  laryngeal  muscles. 

Anatomic  Alterations. — Paralysis  of  the  laryngeal  muscles 
may  have  existed  without  appreciable  anatomic  alterations  in 
nerves  or  muscles.  In  other  instances  degenerative  changes  are 
found  in  the  nerves  or  muscles,  or  in  both. 

Symptoms. — Paralysis  of  the  muscles  of  the  larynx  can  be 
recognized  with  certainty  only  with  the  aid  of  the  laryngoscope. 


90 


RESPIRATORY  ORGANS 


A  distinction  has  been  made  between  respiratory^  phonatory,  and 
mixed  paralyses  of  the  larynji^eal  muscles  accordingly  as  the  paral- 
ysis gives  rise  to  disturbances  in  respiration  or  of  voice-formation, 
or  to  both  sets  of  phenomena. 

Paralysis  of  t/ie  posterior  crico-arytenoid  mvAicles  is  of  the  respir- 
atory type,  as  voice-formation  is  not  at  all  affected,  -while  inspira- 
tion is  rendered  difficult  and  stridulous,  because  the  vocal  bands 
do  not  separate  during  inspiration,  but  are  brought  together  at 
their  free  margins  by  aspiration  (Fig,  11).  The  patient  is  com- 
pelled to  breathe  Avith  great  care,  as  rapid  and  vigorous  respiration 
readily  induces  complete  closure  of  the  chink  of  the  glottis. 
Paralysis  of  the  posterior  crico-arytenoid  muscles  takes  place  not 
rarely  in  hysterical  patients.     If  the  paralysis  is  but  unilateral. 


Fig.  11. — Laryriisoscopic  appearances  pre- 
sented by  paralysis  of  the  posterior  crico- 
arytenoid muscles ;  inspiratory  position. 


Fig.  12. — Laryngoscopic  appearances  pre- 
sented by  paralys^is  of  the  right  posterior 
crico-arytenoid  "muscle  during  inspiration. 


the  vocal  band  upon  the  paralyzed  side  remains  in  the  middle  line 
during  inspiration  (Fig.  12). 

Parcdysis  of  the  arytenoid  muscles  causes  separation  of  the  pos- 
terior third  of  the  chink  of  the  glottis  (cartilaginous  glottis)  during 


Fig.  13.— Laryngoscopic  appearances  pre- 
sented by  paralysis  of  the  arytenoid  muscles 
during  phonation. 


Fig.  14.— Laryngoscopic  appearances  pre- 
sented by  paralysis  of  the  internal  thyro- 
arytenoid muscles  during  phonation. 


phonation  (Fig.  13),  while  paralysis  of  the  internal  thyro-arytenoid 
muscles  causes  separation  of  the  anterior  two-thirds  of  the  cliink 
of  the  glottis  (Fig.  14).    Not  rarely  both  pairs  of  muscles  are  para- 


PARALYSIS  OF  THE  MUSCLES  OF  THE  LARYNX 


91 


lyzed  sirniiltaneoiisly,  which  may  be  recognized  in  the  laryngoscope 
from  the  fact  that  during  phonation  both  the  posterior  third  and 
the  anterior  two-thirds  of  the  chink  of  the  glottis  remain  widely 
open,  and  are  separated  by  the  projecting  vocal  process  of  the 
arytenoid  cartilage  (Fig.  15).  Paralysis  of  one  internal  thryo- 
arytenokl  muscle  causes  the  vocal  baud  upon  the  paralyzed  side  to 
form  a  convexity  outward  during  phonation  (Fig.  16).     Paralysis 


Fig.  15. — Laryngoscopic  appearances  pre- 
sented by  paralysis  of  the  arytenoid  and  the 
internal  thyro-ayrtenoid  muscles  during 
phonation. 


Fig.  16. — Laryngoscopic  appearances  pre- 
sented by  paralysis  of  the  left  internal 
thyro-arytenoid  muscle  during  phonation. 


of  the  lateral  thyro-arytenoid  and  the  external  thyro-arytenoid  mus- 
cles cannot  be  recognized  from  any  peculiarity  of  the  laryngoscopic 
appearances. 

With  paralysis  of  one  recurrent  laryngeal  nerve,  which  inner- 
vates the  muscles  thus  far  named,  the  true  vocal  band  upon  the 
paralyzed  side  remains  immobile  during  breathing  and  speaking. 


Fig.  17. — Laryngoscopic  appearances  pre- 
sented by  paralysis  of  the  left  recurrent 
laryngeal  nerve  :  cadaveric  position  of  the 
left  vocal  band  ;  inspiratory  position. 


Fig.  18. — Laryngoscopic  appearances  pre- 
sented by  paralysis  of  the  left  recurrent 
laryngeal  nerve  during  phonation. 


It  assumes  the  position  that  is  observed  in  the  cadaver ;  whence 
the  designation  cadaveric  position,  viz.,  midway  between  the  median 
position  and  the  extreme  lateral  position  (Fig.  17).  In  phonation 
the  chink  of  the  glottis  is  closed,  because  the  healtliy  vocal  band 
is  drawn  beyond  the  median  line,  and  becomes  applied  to  the  free 
margin  of  its  paralyzed  fellow.  At  the  same  time  the  arytenoid 
cartilages  overlap,  that  of  the  healthy  side  being  placed,  as  a  rule, 


92  RESPIRATORY  ORGANS 

in  front  of  its  fellow  (Fig.  18).  It  is  noteworthy  that  the  chink 
of  the  glottis  follows  an  oblique  course.  Changes  in  the  voice 
and  iuterference  with  all  acts  of  expiration  (cough,  expulsion)  may 
be  entirely  wanting. 

Panihjsia  of  both  recurrent  laryngeal  nerves  gives  rise  to  per- 
sistent separation  of  the  vocal  bands,  which  maintain  the  same 
position  during  breathing  and  speaking.  Both  vocal  bands  assume 
the  cadaveric  position.  Expulsion,  cough,  and  loud  speaking 
are  impossible  when  closure  of  the  chink  of  the  glottis  cannot  be 
effected. 

Paralyfiis  of  the  thyro-ary-epiglottio  muscles,  which  are  inner- 
vated by  the  superior  laryngeal  nerve,  manifests  itself  function- 
ally by  the  frequent  aspiration  of  swallowed  substances  into  the 
larynx  because  the  entrance  to  the  larynx  remains  open  during 
the  act  of  swallowing.  In  consequence  there  is  danger  of  suffo- 
cation, of  aspiration-pneumonia,  of  pulmonary  abscess,  and  of 
pulmonary  gangrene.  On  laryngoscopic  examination  the  immo- 
bility of  the  epiglottis  will  attract  attention. 

Paralysis  of  the  anterior  cricothyroid  muscles  renders  impos- 
sible the  production  of  higher  notes,  as  the  tension  of  the  vocal 
bauds  is  diminished.  Besides,  in  the  attempt  at  this,  approxi- 
mation of  the  thyroid  cartilage  to  the  cricoid  cartilage  fails  to 
take  place.  The  laryngoscopic  appearances  are  less  distinctive. 
It  has  been  stated  that  the  middle  of  the  vocal  band  sinks  down- 
ward during  inspiration  and  projects  upward  during  expiration, 
that  the  vocal  process  of  the  arytenoid  cartilage  is  not  visible 
upon  the  paralyzed  side,  and  that  in  the  attempt  to  produce  high 
notes  the  healthy  vocal  band  appears  the  higher  and  the  longer. 

Paralysis  of  the  thyro-ary-epiglottic  and  anterior  cricothyroid 
muscles  is  often  attended  with  anesthesia  of  the  laryngeal  mucoius 
membrane,  for  the  superior  laryngeal  nerve,  which  innervates  the 
muscles  named,  is  likewise  the  sensory  nerve  for  the  laryngeal 
mucous  membrane  down  to  the  chink  of  the  glottis.  In  conse- 
quence there  is  danger  that  aspirated  particles  of  food  may  gain 
entrance  into  the  deeper  air-passages,  and  give  rise  to  inflamma- 
tion, suppuration,  or  gangrene  in  the  lungs,  because  cough  is 
wanting,  which  would  be  capal^le  of  causing  expulsion  from  the 
larynx  of  the  inspired  foreign  body. 

Paralyses  of  long  standing  are  followed  by  atrophy  from  inac- 
tivity of  the  ])aralyzed  muscles. 

Prognosis. — The  prognosis  is  governed  largely  by  the  fact 
whether  the  causative  conditions  are  curable  or  incurable ;  but, 
even  when  curable,  paralysis  of  the  laryngeal  muscles  may  prove 
obstinately  resistant  to  treatment.  In  cases  of  hysteria  and  of 
active  inflammation  the  paralysis  is  frequently  recurrent. 

Treatment. — The  treatment  of  paralysis  of  the  laryngeal 
muscles  must    be    in    the    first  place   directed    to   the    causative 


SPASM  OF  THE  GLOTTIS  93 

condition.  In  addition  local  treatment  should  be  employed, 
and  by  means  of  insufflations,  by  the  application  of  sounds,  by 
loud  speaking  during  laryngoscopic  examination,  by  electricity, 
and  by  inhalation  of  compressed  air,  an  endeavor  should  be  made 
to  stimulate  the  vocal  bands  into  activity.  If  in  consequence  of 
paralysis  of  the  posterior  crico-arytenoid  muscles  danger  of  suffo- 
cation should  arise,  resort  should  be  had  to  intubation  or  tra- 
cheotomy. In  the  presence  of  anesthesia  of  the  laryngeal  mucous 
membrane,  in  consequence  of  paralysis  of  the  superior  laryngeal 
nerve,  nourishment  through  the  stomach-tube  will  be  necessary. 

SPASM  OF  THE  GLOTTIS. 

Symptoms  and  Diagnosis. — Spasm  of  the  glottis,  a  com- 
mon disease  of  early  childhood,  results  from  spastic  contraction  of 
the  muscles  that  close  the  glottis  and  of  the  diaphi-agm.  Children 
that  have  been  carried  upon  the  arm,  and  were  quite  cheerful, 
are  suddenly  seized  with  irregular  breathing.  They  rotate  their 
eyes,  and  finally  close  them ;  the  head  falls  forward,  and  breathing 
ceases  entirely.  At  the  same  time  the  color  of  the  face  undergoes 
a  change,  becoming  pale,  and  then  more  and  more  livid.  The 
pulse  becomes  accelerated  and  often  also  irregular,  and  the  veins 
of  the  neck  become  greatly  distended  with  blood.  After  a  few, 
at  most  thirty,  seconds  respiration  is  again  established,  with  loud 
whistling  or  crowing  inspiration,  consciousness  returns,  and  the 
children  are  soon  as  bright  as  before  the  attack.  Such  attacks 
may  be  repeated  more  than  fifty  times  in  the  course  of  a  day ;  in 
other  instances  the  disease  is  terminated  with  a  single  attack, 
or  the  attack  is  repeated  a  few  times  in  the  course  of  days 
or  weeks.  During  the  attack  the  upper  limit  of  liver-dulness 
can  be  demonstrated  by  percussion  to  occupy  an  unusually  low 
level,  and  this  has  been  attributed  to  spasm  of  the  diaphragm. 
Not  rarely  urine  and  feces  are  passed  involuntarily  toward  the 
end  of  the  attack.  Spasmodic  contraction  of  the  dorsal  flexors 
of  the  fingers,  toes,  hands,  and  feet  occurs  also,  and  at  times  gen- 
eral clonic  muscular  spasm.  Children  with  spasm  of  the  glottis 
not  rarely  present  also  nervous  restlessness,  undue  susceptibility 
to  fright,  disturbed  sleep,  hyperidrosis,  nystagmus,  and  tetany. 
The  individual  attack  frequently  occurs  without  obvious  cause. 
In  other  cases,  however,  it  is  induced  by  psychic  disturbances 
(crying,  laughter,  fright),  by  the  entrance  of  foreign  bodies  into 
the  larynx,  or  by  falling  back  of  the  tongue ;  or  it  occurs  in  con- 
nection with  deranged  digestion. 

Prognosis. — The  prognosis  is  serious  because  of  the  danger 
of  suffocation.  This  is  the  more  alarming  the  more  frequently 
the  attacks  follow  one  another,  the  longer  they  last,  and  the 
younger  the  patient. 


94  RESPIRATORY  ORGANS 

Btiolog^. — As  a  rule,  only  children,  and  especially  between 
the  .sixtii  and  the  twenty-fourth  month  of  life,  are  attacked  by 
spasm  of  the  <i:lottis.  Most  frequently  the  children  have  been 
nourished  artificially,  and  present  signs  of  rachitis.  The  disease 
occurs  with  especial  frequency  in  northern  regions,  and  in  the 
cold  months.  At  times  epidemic  occurrence  has  been  observed. 
An  especial  form  of  the  disorder  is  known  as  spasmus  glottidis 
ahlactatonun,  which  appears  in  some  children  at  the  time  of 
weaning. 

Anatomic  Alterations  and  Nature  of  the  Disease. — 
Distinctive  anatomic  conditions  sufficient  to  explain  the  disease  are 
as  yet  unknown,  and  hypotheses  have  thus  been  given  a  free  field. 
The  disease  has  been  attributed  to  irritation  of  the  vaffo-acces- 
sorius  or  the  recurrent  laryngeal  nerve  by  enlarged  bronchial 
glands  or  by  an  enlarged  thymus  gland,  or  by  a  softened  rachitic 
occiput,  and  the  like.  It  has  'recently  been  maintained  that  spasm 
of  the  glottis  is  merely  a  symptom  of  tetany. 

Treatment. — With  the  onset  of  an  attack  of  spasm  of  the 
glottis  all  constricting  articles  of  clotliing  should  be  removed,  and 
the  child  should  be  raised  up,  as  experience  has  shown  that  the 
dorsal  decubitus  prolongs  the  duration  of  the  attack,  and  it  should 
be  taken  to  an  open  window,  or  into  the  fresh  air.  Respiration 
should  be  stimulated  by  sprinkling  cold  water  upon  the  chest,  by 
tickling  the  soles  of  the  feet  or  the  nasal  mucous  membrane,  or 
bv  application  of  ammonia  to  the  nares  for  inhalation.  If  respira- 
tion is  not  resumed,  the  index-finger  should  l)e  introduced  to  the 
entrance  of  the  larynx  to  determine  whether  possibly  the  epiglottis 
has  not  been  impacted  posteriorly  in  consequence  of  spasm  of  the 
thvro-arv epiglottic  muscles.  Tracheotomy  and  intubation,  and 
faradization  of  the  phrenic  nerves  have  also  been  recommended. 
If  the  attacks  recur  frequently  in  the  course  of  the  day,  the  little 
patient  may  be  kept  slightly  under  the  ijifluence  of  chloroform  or 
of  ether.  For  the  general  nervous  condition  nervines  have  been 
advised,  for  instance,  sodium  bromid  (5.0:100;  ]0  c.c. — a  des- 
sertspoonful— every  two  hours).  In  cases  of  spasmus  glottidis 
ablactatorum  the  child  must  again  be  applied  to  the  breast  and 
the  process  of  weaning  deferred  for  a  short  time.  Among  prophy- 
lactic measures  appropriate  nourishment  and  the  treatment  of 
possible  rachitis  must  be  considered. 

PHONATORY  SPASM  OF  THE  GLOTTIS  (SPASTIC 

APHONIA). 

Bv  phonatory  spasm  of  the  glottis  is  understood  a  spastic  con- 
traction especially  of  the  tensors  of  the  vocal  bands,  which  sets  in 
whenever  the  patient  makes  an  attempt  to  speak.  The  disorder 
is  thus  suggestive  of  the  coordinatory  occupation-neuroses.     The 


LARYNGEAL   COUGH  95 

patients  are  unable  to  speak  aloud,  and  complain  principally  of  a 
sense  of  pressure  in  the  region  of  the  larynx  and  within  the  inte- 
rior of  the  thorax.  The  explosive  consonants,  such  as  b,  p,  d,  t, 
k,  g,  are  best  enunciated.  Most  frequently  the  patients  are  ner- 
vous and  hysterical  individuals,  although  the  affection  occurs  also 
in  connection  with  tabes  dorsalis  and  multiple  sclerosis.  At  times 
exposure  to  cold  or  over-use  of  the  vocal  bands  is  assigned  as  the 
cause.  In  addition  to  treatment  of  the  primary  condition,  care 
of  the  voice,  electricity,  and  applications  of  cocain  (1  :  10)  to  the 
larynx  have  been  recommended. 

SENSORY  DISORDERS  OF  THE  LARYNGEAL  MUCOUS 

MEMBRANE* 

1.  Anesthesia  of  the  laryngeal  mucous  membrane  occurs,  as  has 
been  mentioned,  in  association  Avith  paralysis  of  the  superior 
laryngeal  nerve,  and  then  extends  down  to  the  free  border  of 
the  vocal  bands.  At  times,  however,  the  anesthesia  involves  the 
entire  larynx  down  to  the  mucous  membrane  of  the  trachea.  The 
condition  is  to  be  recognized  from  the  fact  that  irritation  of  the 
laryngeal  mucous  membrane  with  a  sound  induces  no  reflex  move- 
ment. Further,  coujjh  is  not  excited  when  foreisrn  bodies  enter 
the  larynx  in  swallowing.  For  this  reason  such  bodies  may 
readily  gain  eutrance  into  the  deeper  air-passages,  and  give  rise  to 
serious  inflammation  in  the  lungs.  Hysteria,  diphtheria,  lead- 
poisoning,  and  bulbar  paralysis  are  the  most  common  causes  of  the 
disorder. 

Treatment  should  be  directed  against  the  primary  affection. 
In  addition,  nourishment  by  means  of  the  stomach-tube  and  the 
employment  of  electricity  are  to  be  recommended. 

2.  Hyperesthesia  and  paresthesia  of  the  larynx  are  attended 
with  a  sense  of  tickling  or  burning,  or  even  pain,  in  speaking,  so 
that  the  patients,  who  are  principally  nervous  and  hysterical  per- 
sons, are  oppressed  l)y  the  belief  that  they  are  suffering  from  some 
severe  laryngeal  disease.  They  speak  only  in  ^vhispers,  or  avoid 
speech  entirely,  and  endeavor  to  make  their  communications  solely 
in  writing. 

The  treatment  should  be  especially  psychic,  and  should  con- 
sist principally  in  encouragement  and  in  daily  methodical  speech- 
exercises. 

LARYNGEAL  COUGH. 

Laryngeal  cough  occurs  principally  in  pale  and  nervous  per- 
sons, who  at  times  assign  their  trouble  to  exposure  to  cold  or  over- 
use of  the  voice.  The  cough  at  times  appears  paroxysmally ;  at 
times  it  is  uninterrupted,  and  not  rarely  acquires  a  barking  or 
whistling  character.     At  the  same  time  examination  of  the  rcspi- 


96  RESPIRATORY  ORGANS 

ratorv  organs  fails  to  disclose  the  slightest  alteration.  Gentle 
encouragement  and  change  of  residence  are  the  most  reliable  reme- 
dies. 

MYCOSIS  OF  THE  LARYNX. 

At  times  fungous  vegetations  occur  upon  the  mucous  membrane 
of  the  larynx,  forming  grayish  or  yellowish  deposits.  In  a  case 
under  my  observation  the  fungi  consisted  of  leptotiirix-filaments, 
in  another  of  cocci  (staphylococcus  pyogenes  albusj  and  l)acilli. 
The  fungous  masses  may  be  present  simultaneously  in  the  pharynx 
and  in  the  trachea.  Cases  are  also  on  record  in  which  only  the 
mucous  membrane  of  the  trachea  was  involved.  The  disorder  is 
exceedingly  obstinate.  I  have  observed  the  best  results  from  inha- 
lations of  mercuric  chlorid  (0.1  :  100). 


III.    DISEASES   OF  THE  TRACHEA. 


The  diseases  of  the  trachea  usually  arise  by  extension  from  the 
larynx  or  the  bronchi,  and  do  not  occur  as  independent  affections. 
If  the  chink  of  the  glottis  be  dilated,  the  tracheal  mucous  mem- 
brane can  be  observed  with  the  aid  of  the  laryngoscope. 


IV.    DISEASES  OF  THE   BRONCHI. 


BRONCHIAL  CATARRH. 

Ktiology. — Bronchial  catarrh  is  one  of  the  commonest  of 
diseases.  It  occurs  at  all  periods  of  life  and  in  both  sexes  with 
almost  equal  frequency  ;  it  attacks  with  especial  frequency  delicate, 
anemic,  and  debilitated  persons,  whose  tissues  have  in  general  suf- 
fered in  their  powers  of  resistance.  It  is  especially  prevalent  at 
times  when  the  weather  is  variable,  particularly  in  the  spring  and 
autumn  months.  Recovery  from  one  attack  of  bronchial  catarrh 
predisposes  strongly  to  recurrence.  A  distinction  must  be  made 
between  a  prima rt/  and  a  s^ecnndarii  bronchial  catarrh  accordingly 
as  the  disorder  occurs  as  an  independent  affection  or  develops  in 
the  course  of  other  diseases.  Secondary  bronchial  catarrh  may 
result  by  extension  of  disease  from  the  larynx,  the  pharynx,  the 
trachea,  and  the  lungs,  but  it  occurs  also  in  conjunction  with  many 
infectious  diseases  ;  for  instance,  influenza,  whooping-cough,  diph- 
theria, measles,  and  typhoid  fever.     The  actual  injurious  agencies 


BRONCHIAL  CATARRH  97 

may  be  divided  into  infectious,  toxic,  trawmatic  (mechanical),  and 
cifxulatory. 

In  all  catarrhal  states  attributed  to  exposure  to  cold  (refrigera- 
tory, rheumatic  bronchial  catarrh)  bacteria  probably  play  the 
actual  exciting  role,  while  the  cold  merely  establishes  a  favorable 
medium  for  their  development  by  causing  changes  in  the  distribu- 
tion of  the  blood  and  the  powers  of  resistance  of  the  tissues.  The 
catarrh  arising  in  the  sequence  of  infectious  diseases  is  likewise 
attributable  to  bacteria.  It  is  true  that  but  little  is  as  yet  known 
with  regard  to  these  organisms.  It  may  be  mentioned  that  influ- 
enza-bacilli have  been  found  in  the  bronchial  secretion  in  cases  of 
influenza-catarrh.  The  significance  of  toxic  influences  may  be 
appreciated  from  the  fact  that  bronchial  catarrh  develops  after 
inhalation  of  irritating  gases  (vapors  of  acids,  chlorin-gas,  and  the 
like).  The  ingestion  of  certain  medicaments  (potassium  iodid^ 
potassium  bromid)  also  is  followed  by  bronchial  catarrh.  Trau- 
matic bronchial  catarrh  induced  by  mechanical  irritants  occurs 
especially  as  an  occupation-catarrh  in  persons  who  by  reason  of 
their  employment  are  exposed  to  the  inhalation  of  dust.  Among 
these  may  be  mentioned  millers,  bakers,  stone-cutters,  hat-makers, 
furriers,  waiters,  and  others.  Heavy  smokers  also,  especially  when 
they  indulge  in  the  practice  of  inhaling  the  smoke,  often  suffer 
from  bronchial  catarrh.  As  the  injurious  influences  under  these 
conditions  are  of  a  persistent  character,  the  resulting  bronchial 
catarrh  also  is  usually  chronic  in  course.  Among  the  varieties  of 
bronchial  catarrh  induced  by  circulatory  disturbances  is  a  hypostatic 
catarrh,  which  develops  especially  in  connection  with  diseases  of 
the  heart  and  chronic  respiratory  diseases,  but  also  with  diseases 
of  the  abdominal  cavity,  when  the  flow  of  venous  blood  to  the 
heart  is  interfered  with.  Further,  in  some  cases  several  causes  are 
probably  operative  simultaneously.  If  speakers,  singers,  and  those 
who  play  on  wind-instruments  suffer  frequently  from  bronchial 
catarrh,  not  only  circulatory,  but  also  mechanical  influences  (alter- 
ations in  the  pressure-relations  of  the  expired  air)  must  be  taken 
into  consideration. 

Anatomic  Alterations. — Acute  bronchial  catarrh  is  charac- 
terized by  redness  and  swelling  of  the  bronchial  raucous  membrane, 
which  is  covered  with  mucous  and  mucopurulent  secretion.  This 
can  be  expelled  from  the  bronchi  by  pressure.  In  cases  of 
chronic  bronchial  catarrh  the  mucous  membrane  exhibits  rather  a 
brownish-red  or  a  grayish-red  color,  and  accumulations  of  secre- 
tion are  also  present.  At  times  trabecular  degeneration  of  the 
bronchial  mucous  membrane  has  taken  place,  as  a  result  of  which 
the  mucous  membrane,  by  reason  of  the  marked  development  of 
the  elastic  layer,  exhibits  prominent  and  variously  branched  pro- 
jections and  ridges.  At  times  loss  of  substance  occurs  in  the 
bronchial   mucous  membrane — bronchial  ulcers :    or  in   other  in- 


98  RESPIRATORY  ORGAXS 

stances  papillary  excrescences  form — bronchial  polypi.  Chronic 
bronchial  catarrh  may  give  rise  also  to  bronchial  dilatation  and 
hyperplasia  of  the  peribronchial  connective  tissue,  and  in  this  way 
to  interstitial  pneumonia. 

Symptoms  and  Diagnosis. — In  many  cases  bronchial 
catarrh  is  attended  only  with  irritation  of  the  air-passages,  cough, 
and  expectoration.  Even  the  most  careful  examination  of  the  air- 
passages  fails  to  disclose  any  local  alteration.  Such  conditions  are 
present  when  the  catarrh  is  seated  at  the  commencement  of  the 
large  bronchi.  Among  the  local  si/mptoms  the  occurrence  of  rales 
or  rhonclii  is  distinctive  of  bronchial  catarrh.  Dry  nlles,  rhonchi 
siccl,  occur  when  the  catarrhal  condition  is  attended  with  swelling 
of  the  bronchial  mucous  membrane  and  the  production  of  a  viscid 
secretion — so-called  dry  bronchial  catarrh.  If  the  catarrh  is  seated 
exclusively  in  the  large  bronchi,  snoring  (sonorous  rales),  rhonohiis 
sonorus,  occurs,  while  with  catarrh  of  the  finer  bronchial  tubes 
whistling  (sibilant  rales,)  rhonchus  sibilans,  occurs.  Often  sonorous 
and  sibilant  rales  are  present  together,  because  the  catarrh  is  dis- 
tributed throughout  the  entire  bronchial  tree.  It  can  then  readily 
be  observed  that,  in  accordance  with  the  direction  of  the  current 
of  air,  sonorous  rrdes  first  become  audible  during  inspiration  and 
then  sibilant  relies,  wdiile  conversely  during  expiration  sibilant 
rales  are  heard  first  and  then  sonorous  rales.  Xot  rarely  the 
sounds  are  so  loud  that  they  can  be  heard  across  a  room.  They 
may  at  times  also  be  felt  through  the  chest-wall  as  a  vibration 
on  palpation — so-called  broncMal  fremitus.  In  a  case  of  pure 
bronchial  catarrh  the  percussion-note  always  remains  clear.  The 
respiratory  murmur  likewise  always  retains  its  vesicular  char- 
acter, although  it  may  be  unusually  sharp,  or  interrupted  or 
jerky,  if  the  catarrh  be  irregularly  distributed  in  the  smaller 
bronchial  tubes ;  or  the  expiratory  murmur  appears  strikingly 
prolonged  in  comparison  with  the  inspiratory  murmur.  Vocal 
fremitus  and  bronchopliony  at  most  undergo  transitory  diminution 
in  cases  of  bronehial  catarrh  if  the  lumen  of  the  bronchi  is  con- 
.stricted  or  temporarily  occluded  by  masses  of  secretion. 

In  cases  of  bronchial  catarrh  with  readily  movable  or  fluid 
secretion,  so-called  moist  bronchial  catarrh,  moist  rdles,  or  bubblinr/, 
rhonchi  hnmidi,  occur.  AVhile  dry  rales  are  dependent  upon 
stenosis,  moist  rales  are  due  principally  to  bursting  of  the  bubbles 
into  which  the  secretion  is  thrown  by  the  respiratory  air.  In 
accordance  with  the  number  of  bubbles  a  distinction  is  made 
between  abundant  and  scanty  bubbling,  and  in  accordance  with 
their  size  between  large,  small,  and  luedium  bubbling  rales.  An 
abundance  of  nlles  is  indicative  of  the  fluidity  and  the  amount  of 
the  bronchial  secretion  ;  while  the  size,  on  the  other  hand,  is  sug- 
gestive of  the  site  of  origin,  as  large-sized  rales  cannot  develop  in 
the  smaller  bronchi.     ISIost  frequently  moist  rSles  are  heard  only 


BRONCHIAL   CATARRH  99 

during  inspiration  or  during  both  inspiration  and  expiration. 
Rarely  they  are  audible  exclusively  during  expiration.  Accord- 
ingly as  the  bubbling  takes  place  in  the  superficial  or  the  deep 
bronchi  a  distinction  is  made  bet^A'een  clear  (loud)  and  dull  (faint) 
moist  rales.  An  intensification  of  the  rales  (consonance)  does  not 
take  place  in  cases  of  pure  bronchial  catarrh.  Frequently  an 
attack  of  bronchial  catarrh  begins  with  dry  rales  and  terminates 
with  moist  rales,  because  the  bronchial  secretion  is  at  first  viscid, 
and  only  later  becomes  diffluent. 

Cough  is  a  constant  and  troublesome  symptom  of  bronchial 
catarrh.  It  often  deprives  the  patient  of  rest  at  night,  and  not 
rarely  causes  severe  thoracic  pain  by  overstretching  of  the  muscles. 
The  more  closely  the  catarrh  is  situated  to  the  bifurcation  of  the 
trachea,  the  more  troublesome  is  the  irritation  of  the  air-passages, 
because  the  bronchial  mucous  membrane  in  this  situation  is  espe- 
cially sensitive.  Severe  cough  may  give  rise  to  vomiting,  and  also 
to  hemoptysis.  It  is  also  frequently  attended  with  distention  of 
the  cervical  and  frontal  veins,  and  as  a  result  of  the  venous  stasis 
the  patients  complain  of  vertigo,  mental  confusion,  and  headache. 
At  times  severe  cough  is  attended  with  involuntary  evacuation 
of  urine,  especially  in  elderly  women ;  less  commonly  the  bowels 
are  moved  involuntarily.  At  times  obstinate  cough  leads  to  the 
development  of  hernia  or  prolapse  of  the  rectum. 

The  expectoration  varies  in  accordance  with  the  duration  and 
the  nature  of  the  bronchial  catarrh,  and  a  variety  of  forms  of 
chronic  bronchial  catarrh  especially  have  been  distinguished  in 
accordance  witli  the  character  of  the  sputum.  In  cases  of  acute 
bronchial  catarrh  the  expectoration  is  at  first  scanty,  viscid,  vit- 
reous, mucous  (sputum  crudum),  and  on  microscopic  examination 
is  found  to  contain  in  a  mucous  ground-substance,  coagulating  on 
addition  of  acetic  acid,  only  scantily  distributed  mucus-cells  or  pus- 
cells  (polynuclear  round  cells).  Later  the  expectoration  becomes 
more  abundant  and  more  diffluent,  and  it  exhibits,  in  addition  to 
the  transparent  mucous  masses,  greenish,  opaque,  purulent  points. 
Such  sputum  is  described  as  mucopurulent,  sputum  coccum  of  a 
former  day. 

The  respiration  is  accelerated  and  even  embarrassed  in  cases  of 
extensive  bronchial  catarrh,  so  that  inspiratory  retraction  of  the 
intercostal  spaces  and  participation  of  the  auxiliary  muscles  of 
respiration  may  be  observed.  In  cases  of  chronic  bronchial 
catarrh  functional  hypertrophy  of  individual  auxiliary  muscles  of 
respiration — for  instance,  the  sternomastoid — may  gradually  take 
place.  The  greater  the  embarrassment  of  respiration,  the  more 
intense  does  cyanosis  of  the  skin  and  mucous  membranes  become. 
Venous  stasis  also  develops.  The  veins  of  the  neck  often  become 
swollen  to  the  size  of  blue  cords  as  thick  as  a  finger,  which  collapse 
with  each  inspiration,  to  become  actively  distended  during  expira- 


100  RESPIRATORY  ORGANS 

tion.  The  lips  form  thick  blue  cushions,  and  the  eyeballs  protrude 
markedly  on  account  of  the  swelling  of  the  retrobulbar  veins. 
Speech  appears  interrupted  and  jerky. 

In  accordance  with  the  duration  a  distinction  is  made  between 
acute  and  chronic  bronchial  catarrh.  Acute  bronchial  catarrh  is 
not  rarely  attended  with  febrile  movement,  though  the  tempera- 
ture does  not  usually  attain  a  high  degree,  and  generally  it  pursues 
an  irregular  course.  If  the  catarrh  be  seated  in  the  larger  bronchi, 
the  patients  frequently  complain  of  a  feeling  of  soreness  beneath 
the  sternum,  in  addition  to  the  distressing  cough.  Catarrh  of  the 
smaller  bronchial  tubes  is  known  also  as  bronchiolitis.  In  eliildren 
and  aged  persons  especially  this  is  by  no  means  free  from  danger, 
as  suffocation  may  take  place  and  bronchopneumonia  (catarrhal 
pneumonia)  may  he  readily  superadded  to  bronchiolitis.  Bronciiio- 
litis  is  distinguished  by  the  presence  of  small,  widespread  mucous 
rales  on  auscultation.  If  the  disease  pursues  an  unfavorable  course, 
the  cyanosis  becomes  more  and  more  marked  by  reason  of  exces- 
sive accumulation  of  carbon  dioxid  in  the  blood,  breathing  becomes 
increasingly  accelerated  and  embarrassed,  consciousness  becomes 
obscured,  and  death  not  rarely  takes  place  in  the  midst  of  eclamp- 
tic convulsions.  The  duration  of  acute  bronchial  catarrh  varies 
from  a  few  days  to  four  or  six  weeks. 

Chronic  bronchial  catarrh  not  rarely  persists  throughout  the 
whole  of  life.  Naturally  periods  of  improvement  and  of  aggrava- 
tion occur,  the  latter  usually  being  dependent  upon  exposure  to 
cold,  and  meteorologic  conditions,  and  being  attended  with  fever. 
A  dry  chronic  bronchicd  catarrh  has  been  described  in  which 
patients  expel  a  small  amount  of  tough,  vitreous  grayish  sputum 
with  violent  coup-hino;  and  strainintr.  Conversely,  in  cases  of 
simple  bronchorrhea  large  amounts  of  mucopurulent  sputum  are 
expectorated,  the  purulent  masses  at  times  forming  rolled-up, 
grayish-green  opaque  clumps — globular  sputum  [sputum  globosum). 
Serous  bronchorrhea  likewise  is  characterized  by  abundant  expec- 
toration, which  occurs  in  the  form  of  a  limpid  fluid  suggesting  the 
appearance  of  a  thin  solution  of  mucilage.  Bronchoblcnnorrhea 
is  characterized  by  copious  purulent  and  readily  diffluent  sputum. 
At  times  the  expectoration  undergoes  decomposition,  and  a  putrid 
or  fetid  bronchitis  develops.  This  same  condition  occurs  wath 
especial  readiness  when  chronic  bronchial  catarrh  has  given  rise 
to  dilatation  of  the  bronchial  tubes  and  stasis  of  the  bronchial 
secretion  takes  place  in  the  dilated  bronchial  cavities,  although 
putrid  bronchitis  may  occur  also  in  the  absence  of  bronchial  dila- 
tation. The  sputum  imder  such  conditions  resembles  exactly  that 
of  pulmonary  gangrene,  except  that  shreds  of  pulmonary  tissue 
are  wanting  in  cases  of  putrid  bronchitis.  The  expectoration  has 
a  most  offensive,  penetrating  odor,  and  the  air  about  the  patient 
diffuses  a  most  disagreeable  odor,  not  only  in  the  immediate  neigh- 


BRONCHIAL   CATARRH  101 

borhood  of  the  mouth,  but  also  at  a  considerable  distance.  The 
patients  contaminate  the  air  of  the  room  within  a  short  time,  and 
thus  render  unbearable  the  association  of  others.  The  patients 
themselves  are  also  unpleasantly  conscious  of  the  disagreeable 
odor,  and  not  rarely  lose  their  appetite  entirely  from  a  feeling  of 
disgust.  The  amount  of  sputum  is  usually  considerable  (up  to 
500  c.c.  and  more  per  day),  and  as  a  rule  the  sputum  is  expec- 
torated but  seldom  by  day,  though  always  in  large  amounts — 
so-called  expectoration  in  mouthfuls.  On  standing,  the  sputum 
forms  four  layers  :  an  upper  frothy  layer,  a  second  of  grayish 
masses  of  pus,  then  a  third  usually  grayish-green  serous  layer, 
and  finally,  at  the  bottom,  a  layer  of  sediment.  The  last  often 
contains  yellowish  or  brownish  granules — Dittrich  or  mycotic  bron- 
chial plugs — which  when  compressed  diffuse  a  peculiarly  offensive 
odor,  and  on  microscopic  examination  are  found  to  contain  innum- 
erable bacteria,  fat-drops,  needles  of  fatty  acids,  and  blood- 
pigment.  Some  of  the  bacteria  are  stained  violet  or  dirty-blue 
on  addition  of  iodin,  but  this  color  appears  only  in  the  actual 
body  of  the  bacteria,  while  the  periphery  is  stained  yellow.  These 
structures  have  been  designated  pulmonary  leptothrices,  and  the 
decomposition  of  the  sputum  has  been  attributed  to  them.  At 
times  the  putrid  sputum  loses  its  disagreeable  odor  on  standing 
in  the  air,  but  this  reappears  after  vigorous  shaking. 

Chronic  bronchial  catarrh  is  a  most  troublesome  disorder,  in 
marked  degree  restricting  the  patient  in  his  capacity  for  work  and 
in  the  enjoyment  of  life.  The  disease  is  further  attended  with 
various  dangers.  As  a  result  of  progressive  debility,  death  may 
result  in  aged  persons  especially,  the  condition  having  been  for- 
merly designated  phthisis  pituitosa.  Much  more  frequently  the 
dangers  reside  in  the  complications.  Chronic  bronchial  catarrh  is 
a  frequent  cause  of  alveolar  pulmonary  emphysema.  When  this 
occurs,  the  respiratory  difficulties  are  increased,  and,  in  addition, 
dilatation  and  hypertrophy  of  the  right  ventricle  may  readily  occur, 
because  a  portion  of  the  pulmonary  capillaries  are  destroyed,  and 
also  the  circulation  in  the  bronchial  vessels  is  obstructed.  If  the 
power  of  the  right  heart  now  fail,  hypostatic  manifestations  appear. 
At  first  it  may  be  possible  to  relieve  these  by  means  of  heart- 
tonics  (digitalis) ;  finally,  however,  the  cardiants  fail  to  exert  their 
effect  and  the  patient  dies  as  a  result  of  excessive  stasis.  Putrid 
bronchitis  is  attended  with  the  danger  of  septic  complications, 
including  persistent  febrile  movement,  painful  articular  swellings, 
cerebral  or  spinal  abscesses,  and  the  like.  The  putrefactive  process 
at  times  also  extends  to  the  pulmonary  tissue,  and  gives  rise  to 
gangrene  and  its  sequels. 

Prognosis. — An  attack  of  acute  bronchial  catarrh  often  ter- 
minates in  recovery  within  a  few  days,  and  becomes  dangerous 
only  when  the  smallest  bronchi  throughout  a  vast  extent  are  con- 


102  RESPIRATORY  ORGANS 

stricted  and  occluded.  Chronic  broncliial  catarrh  is,  to  say  the 
least,  a  troublesome  disorder,  the  cure  of  which  may  be  anticipated 
only  when  it  is  possible  to  remove  the  cause. 

Treatment. — Projjhi/lacfic  measures  will  be  required,  among 
others,  in  siieli  persons  as  render  their  body  sensitive.  It  may 
then  be  necessarv  to  harden  the  bodv  intellio^entlv  bv  cold  fric- 
tions.  Those  engaged  in  certain  occupations  are  to  be  guarded 
against  the  inhalation  of  dust  or  irritating  gases  by  the  proper 
construction  of  factories  and  suitable  protective  measures.  Causal 
treatment  is  indicated  especially  in  cases  of  hypostatic  catarrh. 
Obese  persons,  who  likewise  exhibit  a  tendency  to  hypostatic 
catarrh,  should  Ije  recommended  to  get  rid  of  their  superfluous 
accumulation  of  adipose  tissue  by  dietetic  regulations,  or  by  courses 
of  treatment  at  ^Nlarienbad,  Carlsbad,  Homburg,  or  Tarasp.  In 
the  syhiptomatic  treatment  narcotics  will  be  employed  when  the 
irritation  of  the  air-passages  is  unusually  severe ;    for  instance  : 


Or, 


B  Bitter-almond  water,  10.0  (2j  fluidrams) ; 

Morphin  liydrochlorate,  0.1   (Ih  grains). — M. 
Dose  :  lU  dj-ops  for  irritation  of  the  air-passages. 

R  Powder  of  ipecacuanha  and  opium, 

Sugar,  each,  0.3  {4.t  grains). — M. 
Make  10  such  powders. 
Dose.:  1  powder  thrice  daily. 


Expectorants  are  generally  em])loyed  for  the  removal  of  the 
secretion  fmm  the  air-passages.  If  the  secretion  be  viscid  (sono- 
rous or  sibilant  rales),  the  solvent  expectorants  may  be  employed 
(ammonium  chlorid,  apomorphin  hydrochlorate,  camphor,  potas- 
sium iodid) ;  for  instance  : 

R  Ammonium  chlorid, 

Extract  of  licorice,  each,  5.0  (75  grains) ; 

Distilled  water,  sufficient  to  make  200.0  (GJ  fluidounces). — M. 
Dose:  15  c.c.  i\  tablespoonful)  every  two  hours. 

For  moist  bronchial  catarrh  (mucous  rales)  the  irritating  expec- 
torants may  be  prescribed  (ipecacuanha-root,  senega-root,  ani.sated 
solution  of  ammonia,  benzoic  acid) ;  for  instance  : 

R  Infusion  of  ipecacuanha-root,  0.5:180; 

Bitter-almond  water,  5.0  (75  minims) ; 

Sirup  of  raspberry,  15.0  (.}  fluidounce). — M. 

Dose:  15  c.c.  (1  tablespoonful)  every  two  hours. 

R  Decoction  of  senega-root,  10.0:180; 

Anisated  solution  of  ammonia,  5.0  (75  grains) ; 

Simple  sirup,  15.0  (v  fluidounce). — M. 

Dose:  15  c.c.  (1  tablespoonful)  every  two  hours. 

R  Benzoic  acid,  0.3     (4i  grains) ; 

Camphor,  0.05  (|  grain) ; 

Sugar,  0.3     (4^  grains). — M. 

Make  10  such  powders. 
Dose :  1  powder  every  two  hours. 


FIBRINOUS  BRONCHITIS  103 

A  surprisingly  rapid  result  may  be  obtained  at  times  from  the 
use  of  balsamics,  especially  in  cases  of  chronic  bronchial  catarrh. 
"We  recommend  especially  the  use  of  oil  of  turpentine,  myrtol,  or 
creosote  :  for  instance  : 


Or, 


Or, 


K    Oil  of  turpentine,  10.0  (2J  fluidrams). 

Dose :  10  drops  thrice  daily  in  milk. 

R  Myrtol,  0.15  (2^  minims). 

Make  50  such  gelatin  capsules. 

Dose :  1  or  2  capsules  every  two  hours. 

R  Creosote,  0.15  (2*  minims). 

Make  50  such  gelatin  capsules. 
Dose :  1  capsule  every  two  hours. 


Balsamics  are  to  be  recommended  particularly  in  cases  of  putrid 
bronchitis.  ISfot  much  can  be  accomplished  by  the  inhalation  of 
medicaments,  because  these  scarcely  reach  the  deeper  air-passages. 
Some  patients  with  chronic  bronchial  catarrh  are  much  relieved 
by  the  employment  of  compressed  or  rarefied  air  ( pneumatotherapy) 
by  means  of  the  apparatus  of  Geigel-]\Iayr  or  of  AValdenburg,  or 
the  pneumatic  cabinet  or  bells.  A  useful  remedial  measure  is 
frequently  a  change  of  residence.  Persons  of  means  suffering 
from  chronic  bronchial  catarrh  will  do  well  to  visit  places  with 
a  mild,  equable  climate ;  for  instance,  in  the  autumn  and  spring 
Locarno,  Montreux,  Arco,  Gardone,  and  in  the  winter  Nervi, 
Bordighera,  San  Kemo,  Mentone,  Ajaccio  in  Corsica.  In  the 
summer  a  course  of  treatment  with  saline  baths  (Kissingen, 
Reichenhall,  Soden,  Oeynhausen,  Ischl),  or  at  alkaline  or  alka- 
line-chlorid  springs  (Ems,  Selters,  Obersalzbrunn,  Rohitsch, 
Gleichenberg).  In  cases  of  bronchial  catarrh  with  the  presence 
of  an  excessive  amount  of  secretion  in  the  air-passages  the  ad- 
ministration of  an  emetic  is  at  times  indicated  ;  for  instance  : 

R  Solution  of  apomorphin  hydrochlorate,         0.2  :  10.0. 
Dose :  From  0.25  to  0.5  (4  to  8  minims)  subcutaneously. 

Should  the  emetic  fail  by  reason  of  the  presence  of  an  excessive 
amount  of  carbon  dioxid  in  the  blood  and  paralysis  of  the  vomit- 
ing center,  the  patient  should  be  placed  in  a  warm  bath  and  an 
attempt  be  made  to  induce  deep  inspirations  by  pouring  cold  water 
from  a  considerable  height  upon  the  anterior  aspect  of  the  chest, 
or  upon  the  nape  of  the  neck,  thus  in  the  neighborhood  of  the 
respiratory  center. 

FIBRINOUS  BRONCHITIS. 

Anatomic  Alterations. — Fibrinous  bronchitis,  also  desig- 
nated bronchial  croup,  is  attended  with  the  presence  of  an  exu- 
date rich  in   fibrin,  and  in  consequence  coagulable,  which  forms 


104  RESPIRATORY  ORGANS 

tubular  casts  of  the  bronchial  divisions.  These  may,  as  a  rule, 
be  readily  detached  from  the  bronchial  mucous  membrane  without 
marked  loss  of  substance,  although  the  epithelium  of  the  mucous 
membrane  has  disappeared.  Both  the  mucous  membrane  and  the 
contiguous  external  surface  of  the  bronchial  cast  exhibit  frequently 
small  and  mostly  punctate  hemorrhages. 

etiology. — A  distinction  must  be  made  between  primary 
and  secondary  bronchial  croup  accordingly  as  the  fibrinous  bron- 
chitis represents  an  independent  affection  or  occurs  secondarily 
to  preexisting  disease.  Primary  bronchial  croup  is  a  most  rare 
disease,  and  for  which  often  no  cause  can  be  elieired.  At  times 
the  aifection  has  been  found  to  have  a  familial  and  hereditary  dis- 
tribution. In  all  probability  bacteria  must  be  looked  upon  as 
the  true  exciting  cause  of  the  disease,  so  that  heredity  and  familial 
predisposition  are  responsible  only  for  a  tendency  on  the  part  of 
the  bronchial  mucous  membrane  to  be  attacked  by  fibrinous  in- 
flammation. Secondary  bronchial  croup  is  usually  of  subordinate 
importance,  and  occurs  most  commonly  in  conjunction  with  fibrin- 
ous pneumonia.  It  has  been  observed  besides  in  association  wdth 
fibrinous  inflammation  of  the  larynx  (croup),  and  at  times  also  with 
pulmonary  tuberculosis,  measles,  typhoid  fever,  acute  articular 
rheumatism,  and  valvular  disease  of  the  heart.  The  occurrence 
of  fibrinous  bronchitis  has  been  described  also  in  association  with 
diseases  of  the  skin  (herpes,  eczema,  impetigo). 

Symptoms  and  Diagnosis. — Both  secondary  and  primary 
bronchial  croup  can  be  diagnosed  ^yith  certainty  during  life  only 
when  fibrinous  coagula  of  the  bronchial  tubes  are  expectorated. 
These  usually  represent  casts  of  the  smaller  bronchi  in  cases  of 
secondary  bronchial  croup,  whereas  in  cases  of  primary  croup 
they  reproduce  at  times  the  ramifications  of  an  entire  bronchial 
tree.  In  sputum  they  usually  sink  by  reason  of  their  weight  to 
the  bottom  of  the  receptacle  in  which  they  are  collected,  where 
they  generally  appear  as  rolled-up,  grayish  or  yellowish-gray 
masses,  frequently  streaked  with  blood.  If  they  be  removed 
with  forceps  and  be  agitated  in  water,  they  unfold  into  a  delicate 
arborization,  reproducing  with  remarkable  accuracy  the  ramifica- 
tions of  the  bronchi  (Fig.  19). 

On  transverse  section  it  will  be  seen  that  the  bronchial  coagulum  pos- 
sesses a  laminated  structure,  and  that  it  is  at  times  hollow,  at  times  solid. 
Not  rarely  the  solid  central  portion  presents  a  grayish  or  blackish  discolor- 
ation due  to  lung-pigment.  At  times  vesicular  enlargements  appear  on 
individual  branches.  On  microscopic  exawination  fibrin  with  parallel  fibers, 
isolated  round  cells,  at  times  crystals  in  the  form  of  double  pyramids  (v. 
Leyden's  asthma-crystals),  and  nests  of  bacteria  are  found.  The  fibrinous 
coagula  are  soluble  in  lime-water  and  alkalies,  while  their  ground-substance 
swells  in  acetic  and  hydrochloric  acids. 

The  symptoms  of  fibrinous  bronchitis  may  be  exhausted  with 
the  expectoration  of  bronchial  coagula.     In  cases  of  secondary 


FIBRINOUS  BRONCHITIS 


105 


bronchial  croup  this  is  the  rule,  because  usually  only  a  few  of  the 
smaller  bronchi  are  involved  in  the  inflammatory  process.  The 
conditions  are,  however,  different  when  the  larger  bronchi  are 
inflamed,  for  then  signs  of  bronchial  occlusion  appear,  and  suffo- 
cation  threatens.  The  breathing  more  or  less  suddenly  becomes 
accelerated  and  embarrassed.  In  the  distribution  of  the  diseased 
bronchus  occluded  by  a  coagulum,  inspiratory  retraction  takes 
place.  In  addition,  vocal  fremitus  and  all  respiratory  murmur 
are  wanting  in  this  area.     The  threatenino^  manifestations  not 


Fig.  19.- 


-Fibrinous  bronchial  coagulum  from  a  case  of  primary  broncliial  croup;  natural 
size  (personal  observation,  Zurich  clinic). 


rarely  cease  with  surprising  rapidity,  when  bronchial  coagula  of 
considerable  size  are  expelled  and  the  bronchial  passages  are  again 
permeable  to  air.  At  times  bloody  expectoration  follows,  but 
hemoptysis  may  also  precede  the  formation  of  the  coagula.  In 
one  case  I  observed  several  days  later  the  expectoration  of  sputum 
resembling  in  appearance  the  rusty-colored  sputum  of  fibrinous 
pneumonia,  obviously  because  small  bronchial  hemorrhages  had 
taken  place  after  the  expulsion  of  the  bronchial  coagula,  and 
whose  blood  coloring-matter  had  undergone  disintegration  within 
the  bronchi.     At  times,  it  is  true,  fibrinous  bronchitis  is  followed 


106  RESPIRATORY  ORGANS 

by  fibrinous  pneumonia.  Emphysema  of  the  lungs  and  pulmonary 
tuberculosis  have  also  been  observed  in  the  sequence  of  fibrinous 
bronchitis. 

The  course  of  jirinuirj/  jihrinous  bronchitis  may  be  acute,  sub- 
acute, or  chronic,  and,  accordingly,  may  extend  over  a  period  of  a 
few  days,  several  weeks,  or  a  number  of  years.  The  formation 
of  broncliial  coagula  may  recur  paroxysmally,  and  tlie  individual 
attacks  may  be  attended  with  chill  and  fever. 

Progfnosis. — In  cases  of  secondary  bronchial  croup  the  prog- 
nosis depends  upon  the  finulamental  disorder.  In  cases  of  primary 
fibrinous  bronchitis  the  prognosis  is  always  serious,  as  each  recur- 
rent attack  is  attended  with  the  danger  of  suffocation. 

Treatment. — In  order  to  avert  the  dangers  of  fibrinous  bron- 
chitis remedies  directed  to  the  sofution  of  the  bronchial  coagula 
have  been  emphn-ed  (lime-water,  lactic  acid — from  2.0  to  5.0  : 
100;  potassium  carbonate — 1.0:100;  sodium  carbonate — 1.0: 
100 — in  the  form  of  inhalations;  but  probably  only  a  little  of 
the  vapor  penetrates  into  the  bronchi,  quite  apart  from  the  pos- 
sibility of  any  solvent  action).  If  suffocation  threatens,  emetics 
(solution  of  apomorphin  hydrochlorate,  0.2  :  100 ;  from  0.5  to 
1  c.c. — 7^  to  15  minims — sul)cutaneously)  may  be  administered. 
For  the  disorder  itself  mercurial  inunctions  and  potassium  iodid 
(5.0:200;  15  c.c. — 1  tablespoonful — thrice  daily)  have  been 
employed. 

BRONCHIAL  DILATATION  (BRONCHIECTASIS). 

Anatomic  Alterations. — Dilatation  of  the  bronchial  tubes 
involves  most  frequently  those  of  medium  size,  while  the  smaller 
and  especially  the  larger  are  much  less  commonly  affected.  The 
bronchial  dilatations  ai'e  found  with  especial  frequency  in  the  pos- 
terior and  inferior  portions  of  the  lungs,  and  they  are  least  com- 
mon in  the  upper  lobe.  In  accordance  with  their  form  a  distinction 
is  made  between  cylindric,  spindle-shaped,  and  saccular  bronchi- 
ectases. Ci/lindric  bronchiectases  are  characterized  by  the  pecu- 
liarity that  the  bronchial  tubes  affected  do  not  undergo  constric- 
tion toward  the  surface  of  the  lung,  but  remain  at  least  of  equal 
caliber,  and  frequently  exhibit  a  bulbous  dihitation  at  the  ex- 
tremity. Such  a  lironchus  has  not  inapprojirintely  l)een  compared 
with  a  glove-finger  that  has  been  cut  open.  Sjjindlc-sJujpcd 
bronchiectases  represent  gradually  increasing  and  diminishing  dila- 
tations of  a  bronchial  tube.  If  a  number  follow  in  close  succes- 
sion, they  have  been  designated  as  chajjlet-likr  or  bead-lihc.  Sac- 
cular bro))cJiiectases,  finally,  depend  upon  sudden  dilatations  of  the 
bronchial  lumen,  and  accordingly  as  the  dilatation  involves  only 
one  lateral  wall  or  tiu^  entire  lumen  of  the  bronchus  a  distinction 
is  made  between  periphercd   and    axial    bronchiectases.     Saccular 


BRONCHIAL  DILATATION  107 

bronchiectases  also  follow  one  another  at  times  in  quick  succession 
and  thus  give  rise  to  a  chaplet-like  arrangement. 

The  bronchial  wall  exhibits  various  alterations  in  the  dilated 
area.  The  bronchial  raucous  membrane  at  first  appears  thickened 
and  reddened,  but  later  attenuation  takes  place,  and  on  microscopic 
examination  it  will  be  found  that  the  cylindric  epithelial  cells 
have  been  transformed  into  mucous  or  goblet  cells,  and  even  into 
squamous  epithelial  cells.  Often  the  mucous  membrane  presents 
a  lattice-work  projection  into  the  bronchial  lumen,  so-called 
trabecular  degeneration,  which  results  from  atrophy  of  the  un- 
striated  muscular  fibers  and  the  connective  tissue,  with  increased 
development  of  the  elastic  tissue.  Polypoid  hyperplasia  of  the 
bronchial  mucous  membrane,  and  at  times  also  bronchial  ulcers, 
are  observed.  The  cartilage-cells  frequently  exhibit  active  pro- 
liferation, while  the  cartilage  itself  disappears. 

The  number  and  the  extent  of  the  bronchial  dilatations  vary. 
At  times  a  single  bronchiectasis  is  present,  or  there  may  be 
several  dilatations,  and  in  other  instances  an  entire  bronchial 
tree  is  affected.  Not  rarely  bronchial  dilatations  are  present  in 
both  lungs.  In  the  neighborhood  of  bronchiectasis  the  pulmonary 
tissue  is  usually  increased  in  density  and  airless,  in  consequence 
of  interstitial  pneumonia,  and  if  a  number  of  bronchiectases  are 
situated  close  together  the  lungs  acquire  the  appearance  of  a 
coarse-meshed  sponge.  At  times  occlusion  of  the  outgoing  bronchus, 
but  at  times  also  of  the  ingoing  bronchus,  takes  place.  Under 
such  conditions  serous  or  purulent  fluid  accumulates  in  the  closed 
bronchial  dilatation.  This  fluid  may  undergo  inspissation,  case- 
ation, and  calcification,  with  the  formation  of  bronchial  calculi. 
A  tendency  toward  recovery  is  at  times  exhibited  by  the  formation 
of  granulations  upon  the  inner  wall  of  the  bronchiectasis,  with 
adhesions  and  deformity  of  its  walls. 

Ktiology. — Bronchial  dilatations  may  be  divided  into  bi-oncho- 
genic,  pidmogenic,  and  pleurogenic  bronchiectases,  in  accordance  Avith 
their  etiology.  Bronchogenic  bronchiectases  develop  most  frequently 
in  the  sequence  of  chronic  bronchial  catarrh.  Tliey  occur  also  not 
rarely  beyond  bronchial  constrictions,  especially  beyond  occlusion 
dependent  upon  aspirated  foreign  bodies.  Further,  persistent, 
severe  efforts  at  cough  (as,  for  instance,  in  whooping-cough)  may 
give  rise  to  the  disorder.  Pidmogenic  bronckiectases  are  those  that 
develop  in  the  sequence  of  catarrhal,  but  more  frequently  in  that 
of  interstitial,  pneumonia.  Bronchiectasis  is  also  observed  in  cases 
of  pulmonary  tuberculosis.  Pleurogenic  bronchiectasis  develops  in 
the  sequence  of  adhesive  pleurisy. 

Uncommon  varieties  of  bronchial  dilatation  are  the  congenital  and  the 
atelectatic  broncfiiectases,  the  latter  of  which  may  be  present  in  atelectatic 
pulmonary  tissue. 

From  the  nature  of  the  causative  factors  bronchiectasis  is  more 


108  RESPIRATORY  ORGANS 

common  in  adults  than  in  children,  and  it  occurs  Avith  especial 
frequency  in  men  and  in  the  lower  ical/cs  of  life. 

The  precise  conditions  for  the  development  of  bronchial  dilatations  are  not 
known  for  all  cases,  and  vary  in  accordance  with  the  causative  factors. 
Bronchiectasis  often  results  in  consequence  of  exposure  of  the  air  within 
certain  bronchial  sections  to  unusually  high  pressure  during  inspiration,  and 
especially  during  expiration.  Such  conditions  are  present  particularly  in 
cases  of  bronchial  catarrh  and  stenosis  of  the  bronchi.  The  development 
of  bronchiectasis  is  naturally  favored  when  the  wall  of  the  bronchial  tubes 
has  undergone  changes  in  structure  and  thus  also  in  its  powers  of  resist- 
ance. In  cases  of  interstitial  pneumonia  the  bronchi  are  not  rarely  sur- 
rounded circularly  by  newly  formed  connective  tissue,  and  if  this  undergo 
cicatricial  contraction  it  will,  by  traction  outward,  cause  dilatation  of  the 
entering  bronchial  tubes.  If  processes  of  softening  have  taken  place  in 
the  neighborhood  of  bronchial  tubes,  as,  for  instance,  in  cases  of  pulmonary 
tuberculosis,  the  conditions  may  thereby  be  provided  for  the  development 
of  bronchiectasis,  and  the  more  so  as  the  bronchial  wall  is  frequently  also 
involved  and  has  become  more  yielding.  An  unequal  distribution  of  the 
air  in  the  lungs  and  over-distention  of  certain  sections  of  the  bronchial 
tubes  with  secretion  must  also  be  considered  as  a  cause  for  bronchiectasis. 

Symptoms  and  Diagnosis. — Three  symptoms  in  particular 
are  important  for  the  recognition  of  bronchial  dilatation  :  in  the 
first  place,  manifestations  of  the  ])resence  of  a  cavity;  secondly, 
the  expectoration;  and,  finally,  the  attitude  of  the  patient. 

Signs  of  the  presence  of  a  cavity  can  only  be  looked  for  when 
the  bronchiectasis  is  situated  at  the  surface  of  the  lung,  and  pos- 
sesses a  diameter  of  at  least  four  centimeters.  Under  such  circum- 
stances the  percussion-note  is  tympanitic,  or,  over  cavities  as  large 
as  an  apple,  metallic  ;  and  at  the  same  time  it  is  usually  dull, 
because  the  dilated  bronchial  tubes  are  prone  to  be  seated  in  con- 
densed pulmonary  tissue.  The  respiratory  murmur  is  bronchial, 
and  over  large  bronchial  dilatations  metallic.  Such  rales  as  may 
be  present  are  ringing  (consonating),  or  over  cavities  of  a  consider- 
able size  of  a  metallic  ringing  character.  Vocal  fremitus  and 
bronchophony  are  increased  in  the  area  of  the  cavity.  There 
may  also  be  a  cracked-pot  sound,  Wintrich's,  interrupted  AVin- 
trich's,  Gerhardt's,  and  i-espiratory  change  in  note.  An  important 
sign  of  the  presence  of  a  cavity  consists  in  the  alternation  of 
dulness,  absence  of  respiratory  murmur  and  of  vocal  fremitus,  with 
a  tympanitic  percussiou-note,  bronchial  breathing,  and  ringing 
rales,  accordingly  as  the  cavity  is  filled  witli  secretion  or  air. 

In  the  differentiation  of  a  brouehiectatie  cavity  from  a  fubercii- 
loits  carifi/  in  the  lung  it  is  important  to  remember  that  the  latter  is 
usually  developed  in  the  U})per,  and  the  former,  on  the  contrary,  in 
the  lower  portion  of  the  lung,  and  that  bronchial  dilatation  is  imat- 
tended  witli  the  presence  of  tubercle-bacilli  in  the  expectoration, 
providing  that  pulmonary  tuberculosis  lias  not  given  rise  to  the 
bronchiectasis.  Bronchiectasis  is  to  be  differentiated  from  abscess- 
formations  in  the  lungs  by  the  absence  of  pulmonary  tissue  from 
the  expectoration  in  cases  of  bronchial  dilatation.     This  circum- 


BRONCHIAL  DILATATION  109 

stance  is  also  decisive  in  the  differential  diagnosis  from  pulmonary 
anthrax,  for  the  expectoration  may  be  fetid  also  in  cases  of  bron- 
chiectasis if  it  nndergoes  decomposition,  and  putrid  bronchitis  is 
superadded  to  bronchial  dilatation.  It  is  possible  also  for  con- 
fusion to  arise  in  the  differentiation  between  bronchial  dilatation 
and  sacculated  j)yopneumothorax  that  has  ruptured  into  the  lung, 
but  the  development  of  both  diseases  is  different,  and  besides 
cholesterin-plates  and  hematoidin-crystals  are  not  rarely  present 
in  the  expectoration  of  the  last-named  disorder  and  absent  in 
cases  of  bronchiectasis.  Only  rarely  have  blood-crystals  been 
found  also  in  the  expectoration  in  cases  of  the  latter. 

Should  signs  of  the  presence  of  a  cavity  be  wanting,  the  diag- 
nosis of  bronchial  dilatation  will  be  attended  Avith  a  good  deal  of 
difficulty.  It  may  then  be  of  importance  to  recognize  that  large 
moist  rales  are  always  present  only  in  a  single  circumscribed  area. 
At  times  a  probable  diagnosis  can  be  made  from  the  appearances 
of  the  sputum.  Often,  though  by  no  means  constantly,  the  expec- 
toration is  ejected  in  mouthfuls,  the  patient  expectorating  seldom, 
but  on  each  occasion  large  amounts,  which  at  times  may  be  forced 
from  both  mouth  and  nose.  The  expectoration  may  be  purely 
purulent  and  thin,  so  that  it  separates  into  layers  on  standing. 
In  other  instances  it  presents  a  nummular  or  a  globular  appear- 
ance. On  microscopic  examination  it  will  be  found  to  contain  no 
peculiar  element.  Not  rarely  numerous  fattily  degenerated  cells, 
and  even  needles  of  fatty  acids,  are  present.  Red  blood-corpus- 
cles and  elastic  fibers  are  present  only  when  loss  of  tissue  has 
occurred  in  the  wall  of  the  dilated  bronchial  tubes.  In  order, 
under  the  diagnostically  difficult  conditions  just  described,  to 
decide  as  to  the  seat  of  the  bronchial  dilatation,  observation  of 
the  attitude  of  the  patient  is  of  importance,  for,  as  with  all  cavities 
producing  an  abundant  fluid  secretion,  patients  suffering  from 
bronchiectasis  also  lie  upon  the  diseased  side  of  the  chest  in  order 
that  the  cavity  may  become  as  completely  filled  with  secretion 
and  occupy  as  long  a  time  as  possible  in  so  doing,  and  but  seldom 
excite  cough.  Possibly  the  Rontgen  rays  may  help  to  overcome 
some  of  the  diagnostic  difficulties,  and  at  the  same  time  furnish 
information  as  to  whether  an  existing  bronchiectatic  condition  is 
extensive  or  circumscribed,  and  single  or  multiple. 

Bronchiectasis  is  a  chronic  disorder,  w'hich  may  give  rise  to 
varied  complications  and  dangers.  Frequently  febrile  movement 
may  suddenly  appear  for  a  time,  obviously  in  consequence  of 
absorption  of  pus  from  the  bronchial  dilatation,  and  character- 
ized by  its  tendency  to  a  hectic  course,  by  chills  and  sweats,  and 
its  septic  character.  In  addition  there  may  be  marked  pallor, 
great  emaciation,  loss  of  appetite,  and  obstinate  diarrhea.  At 
times  metastatic  inflammcdion  and  suppurrition  occur  in  other 
organs,  for  instance   articular   swelling,  and   cerebral   or  spinal 


1  1  0  RESPIRA  TOR Y  ORGANS 

abscess.  Should  expectoration  be  restrained  the  secretion  may 
undergo  decomposition,  and  symptoms  of  jj  at  rid  broiictiifi.s  appear, 
as  deseril)ed  on  pages  100  and  101.  At  times  copious  and  danger- 
ous hemoptysis  occurs  repeatedly.  There  is  also  danger  of  «//*yo/(Z 
degeneration,  as  with  all  other  varieties  of  protracted  suppuration. 
It  is  of  little  significance  that  at  times  the  terminal  phalauges  of  the 
fingers  and  toes  undergo  bulbous  thickening,  and  the  nails  become 
greatly  curved,  giving  rise  to  the  condition  that  has  been  desig- 
nated d/-nm-sfich  fingers.  At  times  bronchiectases  rupture  into 
the  pleural  cavity,  and  give  rise  to  pyopneumothorax.  They  have 
also  been  observed  to  form  hernia-like  protrusions  through  the 
chest-wall,  and  to  threaten  rupture  externally.  At  times  death 
takes  place  after  years  of  suffering  amid  signs  of  asthenia  or  in 
consequence  of  secondary  puLnonary  tuberculosis.  Some  patients 
die  amid  manifestations  of  stasis,  when  the  contraction  of  the 
limg  accompanying  the  bronchiectasis  has  induced  dilatation  and 
hypertrophy  of  the  right  ventricle,  and  subsequently  weakness 
of  the  dilated  heart  develops. 

Prognosis. — The  prognosis  of  bronchial  dilatation  is  always 
serious,  for  no  internal  remedy  capable  of  curing  the  condition  is 
known,  and  the  number  of  possible  dangers  is  by  no  means  small. 

Treatment. — Bronchial  dilatations  can  be  corrected  only  by 
surgical  measures,  exposing  them  with  the  knife  or  the  thermo- 
cautery and  draining  them,  in  order  to  effect  closure  through  the 
formation  of  granulations.  Xevertheless,  complete  success  can 
be  expected  only  in  the  presence  of  circumscribed  bronchiectasis. 
Hitherto  the  results  of  operative  intervention  have  not  been  overly 
brilliant,  because  the  diagnosis  of  circumscribed  bronchiectasis 
was  not  possible,  but  perhaps  photographic  reproduction  by  means 
of  the  Rontgen  rays  will  change  this  state  of  affairs.  Internal 
remedies  are  not  strictly  directed  against  the  bronchial  dilatation, 
but  against  the  contained  secretion,  and  against  possible  putrid 
decomposition  thereof.  The  employment  of  balsamics  or  of  creo- 
sote especially  is  to  be  recommended  ;  for  instance  : 


Or, 

Or, 
Or, 


R  Oil  of  turpentine,  10.0  (2^  fluidrams). 

Dor^e :  10  drops  thrice  daily  in  milk. 

R  Myrtol,  0.15  (2J  minims). 

Make  30  such  gelatin  capsules. 

Dose :  1  or  2  capsules  every  two  hours. 

R  Oil  of  mountain-pine.  10.0  (2j  fluidrams). 

Dose:   10  drops  in  milk  thrice  daily. 

R  Creosote,  0.15  (2.}  minims). 

Make  30  such  gelatin  capsules. 
Dose :  1  capsule  every  two  hours. 


The  strength  of  the  patient  should  be  maintained  by  a  nutritious  diet. 


BRONCHIAL  CONSTRICTION  111 

BRONCHIAL   CONSTRICTION    (BRONCHOSTENOSIS;. 

Ktiology. — Bronchial  constriction  may  be  of  intrahronchial, 
'parietal,  or  extrabronchial  origin.  Tntrabronchial  constriction 
includes  not  only  that  resulting  from  aspirated  foreign  bodies,  but 
collections  of  mucus,  pus,  blood,  fibrinous  coagula  and  parasites  that 
have  perforated  and  become  lodged  in  the  bronchi  are  also  ^vell 
adapted  to  induce  constriction  of  the  bronchial  passages.  Parie- 
tal bronchostenosis  may  be  due  to  new- growths  and  cicatrices,  and 
with  relative  frequency  to  syphilitic  cicatrices.  The  number  of 
conditions  responsible  for  extrabronchial  or  compression  stenosis  is 
very  large.  Among  these  may  be  mentioned  neoplasms  of  the 
lungs,  of  the  pleura,  of  the  mediastinum,  of  the  esophagus,  and 
of  the  vertebral  column,  aneurysms  of  the  aorta,  retrosternal 
goiter,  and  new-growths  of  the  thymus  gland. 

Anatomic  Alterations. — Bronchial  stenosis  can  be  readily 
recognized,  as  the  bronchial  cavity  at  the  atfected  point  is  con- 
stricted and  at  times  occluded.  In  other  respects  the  anatomic 
alterations  vary  in  accordance  with  the  individual  causative  factor. 
Below  the  point  of  constriction  dilatation  of  the  bronchial  tube 
not  rarely  takes  place. 

Symptoms  and  Diagnosis. — The  symptoms  of  bronchial 
constriction  manifest  themselves  in  evidences  of  embarrassed  or 
suspended  respiration  in  the  distribution  of  the  atfected  bronchial 
tube.  They  are  the  more  conspicuous  and  the  more  readily  recog- 
nizable the  larger  the  tubes  involved.  If,  for  instance,  a  main 
bronchus  is  occluded,  perhaps  by  an  aspirated  foreign  body,  the 
corresponding  side  of  the  chest  will  participate  but  slightly  if  at  all 
in  the  respiratory  movements,  and  inspiratory  retraction  of  the  inter- 
costal spaces  will  become  visible.  Breathing  may  be  rendered 
difficult  and  require  the  aid  of  the  auxiliary  muscles  of  respnration. 
Inspiration  appears  especially  slowed  and  embarrassed,  and  as  a 
result  respiratory  action  is  retarded.  After  a  time  the  air  in  the 
obstructed  pulmonary  area  becomes  absorbed,  and  accordingly 
retraction  of  tbe  affected  side  of  the  chest  takes  place,  while  the 
opposite  side,  in  consequence  of  excessive  distention  of  the  healthy 
lung  with  air,  is  conspicuous  for  its  prominence.  Vocal  fremitus 
is  diminished  or  abolished  upon  the  diseased  side  of  the  chest 
because  the  voice-waves  are  intercepted  at  the  constricted  point 
in  their  transmission  into  the  broncliial  tube.  The  j^ercussion-note 
appears  more  and  more  deep  and  tympanitic  in  correspondence 
M'ith  the  increasing  absorption  of  the  air  in  the  occluded  bronchial 
area  and  the  progressive  reduction  in  the  tension  of  the  pulmonary 
tissue.  No  respiratory  murmur  can  be  lieard,  and  no  broncbopbony 
or  but  diminished  voice-transmission.  Usually,  however,  stenotic 
rales  are  audible  at  some  distance,  and  they  may  be  palpable  as 
bronchial    fremitus.       If    bronchostenosis    be    suddenly    removed. 


112  RESPIRATORY  ORGANS 

as,  for  instance,  through  the  expulsion  of  a  foreign  body,  the 
phenomena  described  disappear,  often  with  remarkable  rapidity. 
The  respiratory  disturbances  mentioned  as  attendant  upon  Ijron- 
chial  stenosis  usually  give  rise  to  cyanosis,  which  may  attain 
varying  grades  of  intensity  in  accordance  with  the  situation  and 
the  degree  of  constriction ;  and,  besides,  the  body  often  assumes 
a  passive  attitude,  either  upon  the  diseased  side  of  the  chest,  in 
order  that  the  healthy  lung  may  engage  in  respiration  as  freely 
as  possible,  or  in  the  position  of  orthopnea.  Often  the  dyspnea  is 
manifested  in  the  desperate  and  anxious  facial  expression  of  the 
patient.  The  forehead  is  cool  and  covered  with  sweat.  The  action 
of  the  heart  and  the  pulse  are  accelerated.  At  times,  during  inspira- 
tion, the  pulse  becomes  small,  almost  to  the  point  of  disappear- 
ance, so-called  indsus  irisjji  ratio  lie  intermittens  s.  paradoxus. 

The  development,  course,  and  duration  of  bronchial  stenosis 
depend  upon  the  etiologic  factors.  In  the  case  of  swallowed  for- 
eign bodies  the  entire  clinical  picture  appears  within  the  shortest 
possible  time,  while  in  the  case  of  new-growths  it  develops  slowly 
and  with  gradual  augmentation.  If  the  causes  are  susceptible  of 
removal,  the  bronchostenosis  may  last  perhaps  only  a  few  hours 
or  days,  whereas  if  the  changes  are  slowly  progressive  it  may  per- 
sist for  months.  Under  the  latter  condition  the  interference  with 
respiration  becomes  greater  and  greater  until  death  results  amid 
symptoms  of  suffocation.  It  is  further  noteworthy  that  not  rarely 
attacks  of  increased  difficulty  in  breathing  occur  suddenly,  without 
noteworthy  alteration  in  the  existing  conditions  being  apparent. 
Accumulations  of  secretion  above  the  point  of  constriction  may 
at  times  be  responsible  for  such  conditions,  but  in  other  instances 
these  seem  to  depend  rather  upon  nervous  influences.  Death  may 
take  pla(;e  in  such  an  attack,  although  many  patients  pass  through 
a  considerable  numl^er  of  attacks.  AVhile  the  diagnosis  of  broncho- 
stenosis is  usually  attended  with  no  great  difficulty,  the  recognition 
of  the  causes  may  at  times  be  impossible.  The  history  and  the 
conditions  present  in  adjacent  organs  are  decisive  in  this  con- 
nection. 

Prognosis. — The  prognosis  in  a  case  of  bronchostenosis  de- 
pends upon  the  situation  and  the  degree  of  constriction,  and  upon 
whether  this  is  due  to  removable  or  irremediable  causes.  In  the 
latter  event  it  is  hopeless. 

Treatment. — The  first  indication  of  treatment  consists  in  the 
removal  of  the  cause — causal  therapy.  Various  remedies  are  de- 
serving of  consideration  in  this  connection,  such  as  expectorants, 
emetics,  and  surgical  measures.  If  the  given  indication  cannot  be 
appropriately  met,  symptomatic  treatment  alone  remains.  Under 
such  conditions  resort  will  have  to  be  had  especially  to  morphin, 
in  order  to  ameliorate  the  dyspnea  and  to  render  the  distress  at  all 
bearable. 


BRONCHIAL  ASTHMA  113 


BRONCHIAL  ASTHMA, 

Ktiology. — Bronchial  asthma  is  characterized  by  the  occur- 
rence of  attacks  of  expiratory  dyspnea  induced  by  transitory 
constriction  of  the  smallest  bronchial  tubes.  This  bronchostenosis 
is  sometimes  due  to  spasm  of  the  unstriated  muscular  fibers  that 
surround  the  terminations  of  the  bronchial  tubes  at  the  point  of 
transformation  into  the  infundibula  somewhat  in  the  form  of  a 
sphincter;  at  other  times  it  is  dependent  upon  acute  swelling 
of  the  bronchial  mucous  membrane.  Under  the  conditions  first 
named  the  designation  nervous  bronckial  asthma  is  employed,  and 
the  affection  is  considered  a  neurosis  of  the  vagus,  which  is  believed 
to  innervate  the  bronchial  sphincter.  Under  the  other  conditions 
the  affection  is  designated  catarrhal  bronchial  asthma. 

Some  physicians  maintain  that  in  nervous  bronchial  asthma  spasm  of 
the  diaphragm  takes  place ;  but  I  have  hitherto  always  been  able  to  con- 
vince myself  of  the  presence  of  the  respiratory  movements  of  the  diaphragm 
at  the  time  of  an  asthmatic  paroxysm. 

Bronchial  asthma  is  an  hereditary  disease  in  some  families. 
In  other  instances  the  patients  are  individuals  in  whose  families 
a  nervous  predisposition  is  inherited.  Acquired  nervousness  also 
furnishes  an  undeniable  tendency  to  bronchial  asthma.  Whether 
irritation  of  the  vagus-center  in  consequence  of  hemorrhage,  soften- 
ing, new-growth,  or  the  like,  in  the  medulla  oblongata,  is  capable 
of  giving  rise  to  central  bronchial  asthma,  is  at  least  doubtful. 
Perhaps  toxic  bronchial  asthma  belongs  to  the  central  variety.  It 
has  been  observed  in  connection  with  lead-poisoning,  mercurial 
poisoning,  and  uremia,  and  it  has  been  designated  saturnine,  mer- 
curial, and  uremic  bronchial  asthma.  In  any  event  bronchial 
asthma  has  been  observed  in  connection  with  irritation  of  the  trunk 
of  the  vagus  by  tumors  in  the  neck  and  enlarged  lymphatic  glands. 
Frequently  bronchial  asthma  arises  through  reflex  influences,  and 
diseases  of  the  most  diverse  organs  may  excite  the  affection. 
Among  diseases  of  the  respiratory  organs  themselves  may  be  men- 
tioned morbid  turgescibility  of  the  mucous  membrane  of  the  nasal 
turbinates,  nasal  polypi,  chronic  rhinitis,  polypi  of  the  vocal  bands, 
chronic  catarrh  of  the  laryngeal  and  bronchial  mucous  membrane. 
It  is  noteworthy  that  some  persons  are  attacked  by  bronchial 
asthma  after  exposure  to  certain  odors,  as,  for  instance,  after 
inhalation  of  the  odor  of  roses,  violets,  or  heliotrope  ;  and  after 
inhalation  of  powdered  ipecacuanha-root  or  of  chlorin  gas.  Not 
rarely  the  reflex  in-itation  arises  from  the  digestive  organs,  and 
bronchial  asthma  may  be  observed  in  connection  with  pharyngeal 
polypi,  hypertrophy  of  the  pharyngeal  tonsils,  chronic  pharyngeal 
catarrh,  hypertrophy  of  the  faucial  tonsils,  constipation,  and  intes- 
tinal worms.     At  times  the  ingestion  of  certain  articles  of  food 


314  RESPIRATORY  ORGANS 

(for  ijistance,  some  kinds  of  cheese)  induces  broncliial  asthma. 
Diseases  of  the  genito-urinary  apparatus  also  giv(;  rise  to  bronchial 
asthma ;  as,  for  instance,  disphicements  of  tiie  uterus.  Sometimes 
well-developed  bronchial  asthma  attends  diseases  of  the  heart. 

It  has  further  been  contended  that  gout  and  diseases  of  the  i</:i/i  may  be 
attended  with  bronchial  asthma. 

Experience  has  shown  that  bronchial  asthma  attacks  men  more 
commonly  than  women.  Although  it  begins  at  times  in  child- 
hood, the  ])atients  are,  as  a  rule,  usually  between  the  twentieth 
und  the  fortit'th  year  of  life. 

Anatomic  Alterations. — Xo  anatomic  alteration  is  known 
to  be  peculiar  to  bronchial  asthma.  Inflammation  of  the  bronchial 
raucous  membrane,  distention  of  the  lungs,  and  pulmonary  emphy- 
sema are  secondary  alterations. 

Symptoms  and  Diagnosis. — Bronchial  asthma  sets  in,  at 
times,  ill  the  midst  of  perfect  health.  The  individual  attacked 
mav  have  been  healthy  and  cheerful  on  retiring  to  bed  at  night, 
'and  is  aroused  from  profound  sleep  by  an  asthmatic  paroxysm.  In 
other  instances  the  patient  anticipates  the  advent  of  an  attack 
from  having  exposed  himself  incautiously  to  some  irritant  (certain 
odors,  the  ingestion  of  certain  articles  of  food,  and  the  like),  which 
experience  has  taught  is  capable  of  exciting  the  asthmatic  parox- 
ysm. At  times  the  attack  may  be  preceded  by  nervous  manifesta- 
tions, such  as  excitability,  depression,  and  general  restlessness. 

The  asthmatic  attack  is  readily  recognizable.  The  patient  is 
seized  with  extreme  dyspnea,  respiration  is  laliored,  deep  cyanosis 
develops,  and  sonorous  and  sibilant  niles  are  audible  at  a  consid- 
erable distance.  The  facial  expression  is  anxious,  and  the  fiice  is 
covered  with  drops  of  sweat.  The  eyes  protrude  markedly  in  con- 
sequence of  stasis  in  the  retrobulbar  veins.  The  blue  lips  are 
swollen  and  the  veins  of  the  neck  appear  bursting  with  blood. 
The  bodilv  temperature  remains  unaltered,  although  the  pulse  is 
accelerated  and  usually  but  poorly  filled.  On  careful  observation 
it  will  be  found  that  in  the  act  of  breathing  expiration  especially 
is  interfered  with  and  is  prolonged.  This  is  explicable  by  the  fact 
that  the  inspiratory  muscles  are  capable  of  exerting  greater  power 
and  of  overcoming  more  readily  possible  obstructions  in  the  air- 
passages  than  the  feeble  expiratory  muscles,  as  aids  to  which  the 
abdominal  muscles  at  times  act.  The  number  of  respirations  is, 
as  a  rule,  diminished.  On  examination  of  the  thorax  two  phenomena 
stand  out  prominently  :  in  the  first  ]>lace,  the  peculiarly  deep  tym- 
panitic percussion-note,  which  has  been  designated  by  Biermer  as 
the  box-note,  and  also  the  displacement  of  the  margins  of  the 
lungs.  Both  of  these  depend  upon  the  fact  that  the  inspired  air 
still  enters  the  pulmonary  alveoli  with  comparative  facility,  but 
is  unable  to  escape   completely  during  expiration.     As  a  result 


BRONCHIAL  ASTHMA 


115 


overfilling  of  the  lungs  with  air  must  take  place,  and  acute 
pulmonary  distention  thus  occurs.  Only  after  termination  of 
the  asthmatic  paroxysm  does  gradual  escape  of  air  from  the 
lungs  take  place,  so  that  now  the  boundaries  of  the  liver,  which 
were  displaced  downward,  and  the  semilunar  space  have  risen  to 
their  usual  situation,  and  the  area  of  cardiac  dulness,  diminished 
during  the  attack,  resumes  its  ordinary  extent.  The  respiratory 
murmur  is  not  audible,  as  a  rule,  during  the  attack,  among 
other  reasons  because  it  is  suppressed  by  the  loud  sonorous  and 
sibilant  rales.  The  individual  attack  lasts,  as  a  rule,  for  several 
hours,  and  terminates  sometimes  rapidly,  sometimes  gradually. 
Some  patients  will  be  exempt  from  attacks  for  months,  while  in 
others  they  may  be  repeated  daily.  With  the  termination  of  an 
attack  mucopurulent  expectoration  takes  place.  Often,  but  by  no 
means  regularly,  the  asthma-crystals  and  spirals  discovered  by  v. 


>^.>.. 


Fig. 


20.— Asthma-crystals  from  the  expectoration  in  a  case  of  bronchial  asthma  ;  magni- 
fied 275  times  (personal  observation,  Zurich  clinic). 


Leyden  can  be  found.  Asthma-crystals  are  pointed  double  pyra- 
mids that  often  lie  in  groups  in  small  opaque  plugs  of  sputum. 
Further,  they  do  not  occur  in  bronchial  asthma  alone,  but  they  are 
encountered  also  in  bronchial  croup  and  in  the  expectoration  in 
cases  of  echinococcus  of  the  lungs.  I  have  found  them  also  in 
pleural  exudates.  They  have  been  found  in  the  blood,  the  bone- 
marrow,  the  juice  of  the  spleen,  and  in  other  organs  in  cases  of 
leukemia. 

In  contradistinction  from  the  sperm- crystals  that  resemble  tliem,  asthma- 
crystals  are  not  four-sided,  but  six-sided,  on  transverse  section. 

The  spirals  also  have  been  found  not  alone  in  association  with 


116 


RESPIRATORY  ORGANS 


bronchial  asthma,  but  also  in  cases  of  fibrinous  pneumonia  and  of 
bronchial  catarrh.  They  represent  coiled,  often  also  fibrillar, 
filaments,  which  on  microscopic  examination 
not  rarely  display  a  bright  central  thread  in 
their  axis,  around  which  at  times  bright 
threads  yet  wind  (Fig.  21).  In  all  probability 
asthma-spirals  result  from  the  expression  of 
bronchial  secretion  through  narrow  orifices. 


Fig.  21. — Asthma-spirals  from  the  sputum  in  a  case  of  bronchia]  asthma;  magnified  275 
times  (personal  observation,  Zurich  clinic). 


Crystals  of  calcium  oxalate  (octahedra,  envelop-shaped)  and  of  acid  cal- 
cium 'phosphate  are  rarely  found. 

Prognosis. — Although  bronchial  asthma  is  a  distressing  dis- 
order, often  persisting  throughout  life,  it  scarcely  ever  causes 
death,  for,  when  the  cyanosis  becomes  excessive,  the  spasm  of  the 
bronchial  muscles  relaxes  or  the  acute  swelling  of  the  bronchi  sub- 
sides, in  consequence  of  carbon-dioxid  narcosis,  and  the  attack 
comes  to  an  end. 

Treatment. — An  attackofastlima  can  be  most  speedily  relieved 
by  subcutaneous  injection  of  morphin  : 

R     Morphin  hydrochlorate,  0.3  (42-  grains) ; 

Glycerin, 

Distilled  water,  each  5.0  (75  minims). — M. 

Dose:  from  0.2o  to  0.5  (4  to  8  minims)  subcutaneously. 

However,  the  asthmatic  patient  should  never  be  entrusted  witli  a 
syringe  and  a  solution  of  morphin,  as  the  danger  of  morphinism 
is  too  great.  This  danger  renders  it  necessary  for  the  physician  to 
make  use  of  morj)hin  only  in  the  excessively  severe  attacks,  and 
when  these  do  not  occur  too  frequently.  At  times,  however,  the 
patients  have  themselves  accidentally  (liseovered  certain  means  of 
amelioration  ;  for  instance,  the  illumination  of  dark  rooms.  A 
large  number  of  remedies  have  been  recommended  for  the  relief 
of  this  distressing  affection,  among  which  sometimes  the  one,  at 


ALVEOLAR  EMPHYSEMA   OF  THE  LUNGS  117 

other  times  another,  will  prove  efficacious.  Thus,  many  patients 
are  relieved  when  paper  that  has  been  dipped  in  a  solution  of 
potassium  nitrate  is  burned  in  the  room.  Others  use  instead  of 
such  paper  so-called  asthma-cigarets,  which  generally  contain 
stramonium  and  belladonna.  Great  stress  should  be  placed  in 
treatment  on  preventing  recurrence  of  the  attacks.  This  indica- 
tion is  met  by  prophylactic  and  causal  treatment.  Thus,  the  patient 
should  carefully  avoid  such  odors  and  articles  of  food  as  experi- 
ence has  shown  to  be  capable  of  readily  inducing  an  asthmatic 
attack.  Existing  diseases  of  the  nose,  the  pharynx,  etc.,  should 
be  carefully  treated.  In  the  presence  of  chronic  bronchial  catarrh 
the  employment  of  compressed  or  rarefied  air  should  be  recom- 
mended (apparatus  of  Waldenburg,  Geigel,  and  Mayer,  pneumatic 
cabinets).  Pasty  and  arthritic  patients  should  undergo  courses  of 
treatment  at  Carlsbad,  Marienbad,  Tarasp,  Vichy,  or  at  similar 
springs.  At  times  it  is  an  advantage  to  attack  existing  nervous- 
ness by  means  of  a  strict  diet  and  an  appropriate  mode  of  life.  In 
this  connection  change  of  residence  is  not  rarely  of  great  service. 
Some  patients  are  free  from  asthma  at  mountainous  elevations. 
Among  internal  remedies  potassium  iodid  and  bromids  may  be  espe- 
cially recommended.  In  some  cases,  also,  I  have  found  arsenic  to 
be  of  much  good  : 


Or, 


R  Solution  of  sodium  bromid,  15.0  :  200 ; 

Potassium  iodid,  5.0  (75  grains). — M. 

Dose:  1  tablespoonful  thrice  daily  after  eating. 

R  Solution  of  potassium  arsenite, 

Bitter-almond  water,  each  5.0  (75  minims). — M. 

Dose :  10  drops  thrice  daily  after  eating. 


V.  DISEASES  OF  THE  LUNGS. 


ALVEOLAR  EMPHYSEMA  OF  THE  LUNGS. 

Anatomic  Alterations. — Alveolar  emphysema  of  the  lungs 
gives  rise  in  the  first  place  to  dilatation  of  the  alveolar  and  infun- 
dibular spaces.  In  addition  there  occurs  atrophy  of  the  alveolar 
septa,  so  that  adjacent  alveoli  coalesce.  Adjacent  infundibula 
also  enter  into  communication  with  one  another,  and  as  a  result 
unusuallv  large  air-spaces  form  in  the  lungs.  As  may  be  under- 
stood, destruction  of  elastic  tissue  and  of  pulmonary  capillaries  is 
an  associated  phenomenon.  Accordingly,  alveolar  emphysema 
of  the  lungs  gives  rise  to  diminution  in  the  elasticity  of  the  lungs, 
and  to  increase  of  blood-pressure  in  the  pulmonary  artery. 


118  RESPIRATORY  ORGANS 

On  microscopic  examination  an  accumulation  of  fatty  granules  is  found 
around  the  alveolar  epithelium,  with  atrophy  of  the  elastic  fibrous  net^'ork, 
and  fatty  degeneration  of  the  pulmonary  capillaries.  The  last  form  a  loose 
network,  and  are  remarkably  straight,  and  in  places  occluded  or  interrupted. 

A  di.stinction  can  be  made  between  local,  unilateral,  and  bilat- 
eral alveolar  emphysema  of  the  lungs.  The  emphysematous  por- 
tions are  conspicuous  for  their  defi(;iency  in  blood  and  in  pigment, 
their  light-rose  color,  an  absence  of  crepitation  and  a  downy  con- 
sistence on  palpation,  and  the  presence  of  large  air-sacs,  which  at 
times  project  beneath  the  pulmonary  pleura  as  thin  transparent 
bladders  up  to  the  size  of  an  apple.  The  median  anterior  and  the 
lower  margins  of  the  lungs  are  especially  predisposed  to  emphy- 
sematous alterations.  In  cases  of  bilateral  alveolar  em/jJii/sema  of 
the  lungs  the  thorax  is  often  remarkable  for  its  barrel-like  shape. 
On  opening  the  chest  the  lungs  do  not  collapse.  The  lungs  cover 
the  heart  with  their  median  bonders,  and  upon  both  sides  have 
pushed  the  diaphragm  markedly  downward.  Their  margins 
appear  swollen  and  rounded,  and  even  with  the  unaided  eye 
large  air-spaces  can  be  made  out  in  them.  Usually  chronic  bron- 
chial catarrh  exists  in  addition  to  alveolar  emphysema  of  the 
lungs.  The  heart  exhibits  dilatation  and  hypertrophy  of  the  right 
ventricle,  and  frequently  signs  of  venous  stasis  are  present. 

Ktiology. — Alveolar  emphysema  of  the  lungs  may  be  induced 
by  respiratory  disturbances  of  most  varied  kind,  provided  these 
give  rise  to  permanent  increase  in  the  intra-alveolar  air-pressure. 
Most  frequently  such  disturbances  are  effective  during  expiration, 
less  commonly  during  inspiration.  Alveolar  emphysema  of  the 
lungs  developed  durinr/  inspiration  is  observed  in  cases  of  catarrh 
of  the  finer  bronchi  (bronchiolitis),  when,  with  swelling  of  the  bron- 
chial mucous  membrane,  the  power  of  the  muscles  of  inspiration 
is  yet  sufficient  to  aspirate  air  into  the  pulmonary  alveoli,  although 
expiration  is  too  feeble  to  force  the  air  out  again  through  the 
constricted  bronchial  tubes.  Exactly  these  conditions  are  present 
2C'hen  spasm  of  the  bronchial  muscles  takes  place,  such  as  has  been 
observed  in  some  cases  of  bronchial  asthma,  and  in  the  presence 
of  foreign  bodies  in  the  bronchi.  Under  all  such  circumstances 
the  pulmonary  emphysema  is  preceded  by  acute  distention  of  the 
lungs,  which  may  even  undergo  involution  when  the  causes  are 
removed.  Expiratory  alveolar  emphysema  of  the  lungs  may  de- 
velop in  connection  with  all  chronic  diseases  attended  irilh  cough. 
For  this  reason  chronic  bronchial  catarrh  is  one  of  the  commonest 
causes  of  the  disorder.  In  efforts  at  cough  the  air  in  the  lungs 
is  exposed  to  excessive  pressure  because  the  thorax  and  the  dia- 
phragm are  contracted  in  expiration,  while  the  chink  of  the  glottis 
is  at  the  same  time  closed.  The  same  conditions  attend  all  ex- 
pidsive  efforts,  and  it  is,  therefore,  not  surprising  that  pulmonary 
emphysema  is  observed  in  those  who  play  wind-instruments,  in 


ALVEOLAR  EMPHYSEMA   OF  THE  LUNGS  119 

Singers,  speakers,  and  such  persons  as  are  compelled  to  carry 
heavy  weights.  Mountain-climbers  also  not  rarely  suffer  from 
emphysema  of  the  lungs.  A  special  form  of  alveolar  empliysema 
of  the  lungs  is  known  as  vicarious  or  compensatory  alveolar  eiaphy- 
sema  of  the  kings,  which  develops  when  some  portions  of  the  lungs 
are  prevented  from  taking  part  in  the  respiratory  process,  so  that 
other  portions  are  compelled  to  assume  the  functions  of  the  inac- 
tive lung.  Vicarious  alveolar  emphysema  is  not  rarely  unilateral 
if  the  respiratory  disturbance  involves  the  opposite  lung.  Pul- 
monary emphysema  occurs  most  commonly  in  men  and  after  the 
period  of  puberty,  which  is  readily  comprehensible  from  the  nature 
of  the  causative  factors. 

Symptoms  and  Diagnosis. — In  cases  of  bilateral  alveolar 
emphysema  of  the  lungs  the  shape  of  the  chest  is  often  conspic- 
uous, the  thorax  being  barrel-shaped,  dilated,  in  a  permanent 
inspiratory  position,  and  emphysematous.  The  respiratory  move- 
ments of  the  chest  are  restricted,  and  on  pressure  upon  the  thorax 
increased  resistance  is  generally  found,  which  is  dependent  upon 
premature  ossification  of  the  costal  cartilages.  Percussion  yields 
a  deep,  slightly  tympanitic  percussion-note  (box-note),  as  the  tension 
of  the  pulmonary  tissue  has  been  diminished.  The  expiratory 
diminution  in  respiratory  pressure  may  be  demonstrated  directly 
by  means  of  the  pneumatometer  (the  normal  expiratory  pressure 
=  from  30  to  60  mm.  of  mercury)..  The  vital  capacity  of  the 
lungs  also,  which  the  spirometer  shows  to  be  between  2000  and 
4000  c.c.  in  healthy  persons,  is  reduced  in  cases  of  pulmonary 
emphysema.  On  auscultation  the  diminished  intensity  of  vesicular 
breathing  is  striking.  The  area  of  cardiac  dulness  is  unusually 
small,  or  it  has  completely  disappeared,  if  the  median  borders 
of  the  lungs  completely  overlie  the  anterior  surface  of  the  peri- 
cardium. The  heart-sounds  are  remarkably  faint,  as  tlie  lung  over- 
lying the  anterior  aspect  of  the  heart  intercepts  their  trans- 
mission. Tlie  upper  limit  of  hepatic  dulness  is  unusually  low  (in 
healthy  persons  in  the  right  mammillarv  line  between  the  sixth  and 
seventh  ribs)  and  upon  the  left  the  semilunar  space  is  much  re- 
duced. It  is  noteworthy,  further,  that  the  respiratory  displace- 
ment of  the  lower  maro-ins  of  the  luno^s  is  exceedins^lv  slio^ht. 
At  times  the  heart  is  pushed  so  far  down  that  not  only  is  its  pul- 
sation visible  in  the  epigastrium,  but  also  its  right  border  can  be 
felt.  In  the  presence  of  unilateral  alveolar  emphysema  of  the 
lungs,  the  manifestations  described  are  confined  to  the  side  of  the 
chest  containing  the  emphysematous  structures. 

Alveolar  emphysema  of  the  lungs  is  not  rarely  attended  with 
complications.  Almost  constantly  bronchial  catarrh  is  present,  and 
it  may  seriously  aggravate  the  existing  respiratorv  disturbances. 
At  times  a  subpleural  empliysematous  vesicle  ruptures,  and 
pneumothorax  develops.     Not  rarely  the  vigor  of  the  right  ven- 


120  RESPIRATORY  ORGANS 

tricle  gradually  fails,  and  signs  of  venous  stasis  appear  (cutaneous 
edema,  hypostatic  urine,  ascites,  hypostatic  liver,  hypostatic  catarrh 
of  the  stomach  and  intestines,  hydrothorax,  hyperemia  of  the 
brain,  cyanosis,  etc.).  A  large  proportion  of  emphysematous 
patients  die  as  a  result  o^  excessive  stasis  and  of  suffocation,  after 
perhaps  it  had  been  possible  at  first  to  overcome  the  manifesta- 
tions of  stasis. 

Prognosis. — The  prognosis  of  alveolar  emphysema  of  the 
lungs  is  unfavorable,  inasmuch  as  recovery  is  impossible.  On 
the  other  hand,  however,  vicarious  pulmonary  emphysema  must 
be  looked  upon  as  a  favorable  development.  The  tendency  of 
emphysematous  patients  to  chronic  bronchial  catarrh  and  to  myo- 
cardial insufficiency  is  particularly  troublesome.  Life  may,  never- 
theless, be  prolonged  for  many  years. 

Treatment. — Prophylactic  measures  should  be  directed  to  the 
avoidance  of  persistent  increase  in  the  inspiratory  and  expiratory 
alveolar  air-pressure,  or  the  removal  of  such  as  may  be  present. 
Recovery  from  or  improvement  in  pulmonary  emphysema  by 
means  of  internal  remedies  is  impossible.  At  times  some  relief 
is  obtained  through  pneumato therapy.  To  this  end  the  apparatus 
of  ^yaldenburg  or  of  Geigel  and  Mayer,  or  pneumatic  bells,  may 
be  employed.  As  in  cases  of  pulmonary  emphysema  the  act  of 
expiration  is  especially  disturbed,  the  patients  should  be  made 
to  expire  into  rarefied  air.  Gerhardt  suggested,  further,  rhythmic 
compression  of  the  thorax  during  expiration. 

INTERSTITIAL  EMPHYSEMA  OF  THE  LUNGS. 

Ktiology. — Interstitial  emphysema  of  the  lungs  is  a  rare 
disease  Avhich  results  from  the  escape  of  air  from  the  pulmonary 
alveoli  into  the  interalveolar  and  interlobular  connective  tissue 
of  the  lungs.  Often  the  air  passes  in  the  connective  tissue 
accompanying  the  bronchi  to  the  hilus  of  the  lung  and  into  the 
mediastinal  connective  tissue,  whence  it  finds  its  way  into  the  sub- 
cutaneous connective  tissue  of  the  neck,  and  even  beneath  the  skin 
of  the  trunk  and  of  the  extremities.  The  air  may  also  find  its 
^vav  beneatli  the  pulmonary  pleura,  which  it  may  raise  in  the  form 
of  air-containing  vesicles,  and  these  may  at  times  be  arranged  at 
the  boundary  between  adjoining  lobules  like  a  string  of  pearls. 
Should  subpleural  air-vesicles  rupture,  pneumothorax  will  develop. 

Among  the  causes  of  this  disorder  are  severe  efforts  at  cough- 
ing and  expulsive  efforts,  extreme  dyspnea,  ulcerative  disease  of 
the  lungs  and  bronchi,  contusions  of  the  tliorax  and  the  lungs,  too 
vigorous  insufflation  of  air  into  the  larynx  for  asphyxia  of  the 
newborn. 

The  diagnosis  of  interstitial  jmhnonarii  cmphiff<cma  can  only 
be  made  indirectlv  from  the  occurrence  of  subcutaneous  emphysema 


ATELECTASIS  OF  THE  LUNGS  121 

of  the  skin  of  the  neck  (marked  bulging  of  the  skin  in  the  jugular 
fossa,  crepitation  on  palpation)  or  of  pneumothorax,  although  all 
other  causes  for  the  two  conditions  named  must  first  be  excluded. 
Such  disturbances  as  may  be  present  are  manifested  by  dyspnea. 

As  a  rule  spontaneous  absorption  of  the  air  takes  place  after 
a  time,  with  recovery,  so  that  the  prognosis  is  not  unfavorable. 

If  the  dyspnea  be  extreme,  relief  may  be  obtained  by  subcu- 
taneous injection  of  morphin,  but  otherwise  an  expectant  attitude 
should  be  observed. 

ATELECTASIS  OF  THE  LUNGS* 

Ktiology. — Atelectasis  of  the  lungs  indicates  deficiency  or 
absence  of  air  in  the  pulmonary  alveoli.  The  pulmonary  alveoli 
have  either  remained  airless — congenital  pjuhnonary  atelectasis — or 
been  deprived  of  air — acquired  pulmonary  atelectasis.  Congenital 
pulmonary  atelectasis  occurs  in  newborn  children  when  the  air- 
passages  are  obstructed  by  collections  of  mucus,  aspirated  amnial 
fluid,  meconium,  or  the  like,  so  that  distention  with  air  of  the 
pulmonary  alveoli  that  have  been  rendered  airless  during  uterine 
life  is  impossible ;  or  when  the  respiratory  muscles  are  not  suf- 
ficiently powerful  to  dilate  the  thorax  adequately  ;  or,  finally,  when 
the  irritability  of  the  respiratory  center  in  the  medulla  oblongata 
is  so  greatly  diminished  that  a  sense  of  the  need  of  air  does  not 
arise. 

Acquired  pidmonary  atelectasis  may  be  either  obstructive,  com- 
pressive, or  marantic.  If  hronclii  are  obstructed  by  mucus,  blood, 
fibrinous  exudation,  or  foreign  bodies,  or  by  pressure  from  without, 
the  air  in  the  alveolar  area  cut  off  from  the  air-supply  will  be 
absorbed  by  the  blood  and  pulmonary  atelectasis  will  develop. 
Compressimi-atelectasis  develops  most  frequently  in  association  with 
pleural  affections  (pleurisy,  pneumothorax,  pleural  tumors)  that 
give  rise  to  compression  of  the  lungs  to  the  point  of  airlessness. 
It  occurs  also  in  association  with  pericarditis,  dilatation  and  hyper- 
trophy of  the  heart,  aneurysms,  mediastinal  tumors,  and  deformity 
of  the  spinal  column,  as  well  as  with  abdominal  tumors,  meteor- 
ism,  ascites,  peritonitis,  and  tumors  of  the  lungs.  Marantic  pid- 
monary atelectasis  develops  in  association  with  severe  disease,  such 
as  typhoid  fever,  as  the  patient  maintains  the  same  posture,  so 
that  the  respiratory  activity  of  some  portions  of  the  chest  is  in 
consequence  interfered  with.  In  addition  weakness  of  the  respira- 
tory muscles  is  often  a  contributory  factor. 

Anatomic  Alterations. — Atelectatic  areas  are  most  common 
upon  the  surface  of  the  lungs.  They  are  conspicuous  by  a})pear- 
ing  depressed  and  by  not  crepitating  upon  pressure  with  the  finger, 
and  they  present  a  dark-red  or  grayish-red  color.  On  section  no 
air-bubbles  escape  from  them  on  pressure.     Atelectatic  portions 


122  RESPIRATORY  ORGANS 

of  lungs  sink  in  water.  In  contradistin(!tion  from  inflammatory 
processes  in  the  luniks  they  can  he  readily  again  filled  M'ith  air 
from  the  supplying  hronchus.  AVlien  atelectasis  of  the  lungs  has 
existed  for  some  time,  inflammatory  alterations  may  take  place  in 
the  pulmonary  alveoli,  and  it  will  then  no  longer  be  possible  to  fill 
the  airless  portions  Avith  air  artificially. 

S3rmptonis  and  Diagnosis. — As  may  be  understood,  ex- 
tensive atelectasis  of  the  lungs  causes  disturbances  in  respiration. 
The  patients  breathe  rapidly  and  with  difficulty,  are  cyanotic,  and 
become  stupid.  Physical  examination  of  the  lungs  discloses 
signs  of  airlessness  of  the  pulmonary  tissue  (increased  vocal 
fremitus,  dulness  on  percussion,  bronchial  breathing) ;  but  it  is 
distinctive  of  pulmonary  atelectasis  that  these  phenomena  disap- 
pear within  a  short  time  when  the  position  of  the  patient  is 
changed,  and  he  is  urged  to  fill  the  atelectatic  portions  of  the  lung 
with  air  again.  Small  atelectiitic  areas  remain  concealed  during 
life,  or  at  best  they  may  be  recognized  on  auscultation  by  the  fact 
that  deep  inspiration  is  attended  with  transitory  crepitating  rales, 
when  the  pulmonary  alveoli  are  again  filled  with  air,  and  their 
walls  are  separated  from  one  another.  All  of  the  alterations  are 
best  developed  in  the  posterior  inferior  portions  of  the  lung. 

Prognosis. — Pulmonary  atelectasis  is  a  serious  disease,  as  in 
debilitated  persons  it  can  scarcely  be  avoided,  and  frequently  it 
cannot  be  successfully  treated. 

Treatment. — In  the  presence  of  febrile  and  debilitating  dis- 
ease prophylactic  treatment  will  be  required.  Measures  should  be 
directed  to  the  relief  of  the  debility  and  the  fever,  and  care  should 
be  taken  to  have  the  patient  change  his  posture  frequently.  The 
latter  is  also  important  in  the  presence  of  persistent  atelectasis. 
Baths,  with  cold  douches,  which  stimulate  deep  inspirations  may 
be  recommended.  In  addition  efforts  should  be  made  to  remove 
the  cause  of  the  disorder. 

HYPOSTASIS  OF  THE  LUNGS. 

Anatomic  Alterations. — Pulmonary  hypostasis  develops 
when  patients  have  persistently  occupied  the  same  posture,  and  at 
the  same  time  the  power  of  the  heart  has  failed.  Under  such  con- 
ditions the  movement  of  blood  is  checked  in  the  pulmonary  capil- 
laries and  veins  in  portions  of  the  lungs  the  most  dependent  and 
restrained  in  their  participation  in  the  respiratory  movements, 
principally  in  the  posterior  and  inferior  sections.  The  affected 
portions  present  an  intensely  dark-red  color,  and  on  pressure  give 
exit  to  viscid,  bloody  fluid.  Usually  the  diseased  tissue  is 
deficient  in  air.  After  a  tiuie  blood-plasma  may  accumulate  in 
the  pulmonary  alveoli,  and  it  may  be  admixed  with  desquamated 
alveolar  epithelium  and  with  colorless  and  red  blood-corpuscles. 


EDEMA    OF  THE  LUNGS  123 

Hypostatic  pneumonia  is  often  spoken  of  uiider  such  conditions, 
although  inflammatory  changes  are  generally  wanting. 

Ktiology. — The  most  common  cause  for  pulmonary  hypostasis 
consists  in  febrile  infectious  diseases,  particuhirly  typhoid  fever. 
The  condition  develops  also  in  the  paralyzed,  in  persons  suffering 
from  diseases  of  the  bones  and  joints,  who  are  compelled  to  main- 
tain the  same  posture.  Not  rarely  it  occurs  during  a  prolonged 
death-agony.  Conditions  that  interfere  with  the  expansion  of  the 
lungs  (ascites,  meteorism,  abdominal  tumors)  favor  the  develoj)ment 
of  pulmonary  hypostasis. 

Symptoms  and  Diagnosis. — Pulmonary  hypostasis,  if  at 
all  extensive,  gives  rise  to  respiratory  disturbances  (accelerated 
breathing,  cyanosis,  increasing  mental  confusion).  As  long  as  the 
pulmonary  alveoli  still  contain  air  the  percussion-note  will  be  tym- 
panitic, and  the  vesicular  murmur  enfeebled  in  the  area  of  altered 
pulmonary  tissue.  If,  however,  the  pulmonary  alveoli  are  occu- 
pied by  fluid,  there  may  be  increased  vocal  fremitus,  dulness, 
bronchial  breathing,  and  crepitant  rales.  The  expectoration  is 
frequently  conspicuous  for  its  bloody  appearance.  Pulmonary 
hypostasis  is  distinguished  from  inflammatory  conditions  of  the 
lungs  by  the  absence  of  febrile  manifestations.  In  the  presence 
of  pulmonary  edema  rales  are  audible  over  an  extensive  area. 

Prognosis  and  Treatment. — The  prognosis  is  usually  un- 
favorable on  account  of  the  serious  nature  of  the  causative  condi- 
tions. Prophylactically  much  can  be  accomplished  in  cases  of 
severe  disease  by  frectuent  change  of  posture  and  the  administration 
of  cardiants  for  the  heart  (digitalis,  stimulants,  baths).  The  same 
measures  should  also  be  directed  against  the  existing  hypostasis  of 
the  lungs. 

EDEMA  OF  THE  LUNGS. 

Anatomic  Alterations. — Pulmonary  edema  is  characterized 
by  the  presence  of  serous  fluid  in  the  pulmonary  alveoli,  although 
the  interstitial  connective  tissue  is  also  infiltrated  Avith  the  same 
fluid.  In  accordance  with  the  distribution  of  the  morbid  process 
a  distinction  is  made  between  circumscribed  and  generalized  edema 
of  the  lungs.  On  opening  the  thorax  edematous  lungs  do  not  col- 
lapse, do  not-  crepitate  on  palpation,  but  feel  soft  and  down-like, 
and  on  section  permit  the  expression  of  an  abundance  of  frothy 
fluid,  which  at  times  is  clear  like  water  or  from  yellowish  to  red- 
dish in  color,  and  at  other  times,  in  the  presence  of  considerable 
carbon-particles  in  the  lungs,  is  dark,  or  when  brown  induration 
of  the  lungs  is  present  is  brownish,  and  when  jaundice  exists  is 
icteric. 

Ktiology. — Several  varieties  of  pulmonary  edema  must  be 
recognized.  Hypostatic  edema  of  the  lungs  occurs  when  the  left 
ventricle  fails  in  power,  while  the  right  continues  to  act  with  un- 


124  RESPIRATORY  ORGANS 

diniinislied  vigor.  The  pulmonary  capillaries  then  become  unduly 
filled  with  blood.  The  same  condition  frequently  arises  as  an 
agonal  edema  during  the  death-struggle.  Similar  conditions  are, 
however,  also  observed  not  rarely  in  association  with  diseases  of 
the  heart  and  the  respiratory  ap])aratus.  At  times  ]nilnionary 
edema  is  dependent  upon  abnormal  permeability  of  the  blood-vessels. 
This  may  be  present,  for  instance,  in  nephritis,  carcinoma,  tubercu- 
losis, and  debilitating  diseases  generally.  In  rare  instances  disturb- 
ances in  the  innervation  of  the  pulmonary  vessels  appear  to  give 
rise  to  pulmonary  edema,  which  lias  tlius  been  observed  in  associa- 
tion with  angioneurotic  edema  of  the  skin.  Abnormally  low 
pressure  exerted  upon  the  pulmonary  alveoli  may  also  be  a  cause 
of  pulmonary  edema.  Such  a  condition  has  been  observed  in  the 
sequence  of  puncture  for  pleural  effusion,  in  association  with  occlu- 
sion of  the  lironchial  tubes  by  foreign  bodies  or  exudation,  and 
after  inhalation  of  irrespirable  gases.  Considerable  importance  is 
further  to  be  attached  to  infla minatory  edema  of  the  Jungs.  This 
occurs  at  times  at  the  periphery  of  inflammatory  areas  in  the  lung, 
at  other  times  as  an  independent  affection,  and  it  is  then  perhaps 
appropriately  designated  serous  pneumonia.  The  drinking  of  cold 
liquids,  exposure  to  cold  in  general,  and  hot  baths  have  been  ob- 
served as  provocative  of  such  conditions. 

Symptoms  and  Diagnosis. — The  presence  of  fluid  in  the 
pulmonary  alveoli  is  indicated  by  crepitant  (fine  mucous)  rales, 
which  are  generated  during  inspiration  by  the  separation  of  the 
walls  of  the  dilating  pulmonary  alveoli  from  the  alveolar  contents. 
As  fluid  is  present  in  the  bronchial  tubes  as  well  as  in  the  alveoli, 
it  is  not  surprising  that  medium-sized  and  even  large  mucous  rales 
are  audible  in  addition  to  small  mucous  rales.  In  the  presence  of 
extensive  pulmonary  edema  innumerable  rales  are  audible  at  all 
parts  of  the  chest.  In  addition  a  tympanitic  percussion-note  is  not 
rarely  elicitable,  because  the  tension  of  the  pulmonary  tissue  is 
diminished.  If  the  fluid  in  the  pulmonary  alveoli  is  unaccom- 
panied by  air,  dulness,  bronchial  breathing,  and  increased  vocal 
fremitus  will  be  present.  A  distinctive  feature  of  pulmonary 
edema  is  further  the  expectoration,  which  is  characterized  by  its 
abundance,  fluidity,  and  frotliy  a]>pearance — serous  expectoration — 
so  that  it  has  been  compared  with  white  of  es:g  that  has  been 
beaten  into  snow  and  subsequently  liquefied,  and  with  soapsuds. 
Its  color  is  usually  light  yellowish  or  reddish,  from  admixture 
with  blood.  If  pulmonary  edema  be  superadded  to  fibrinous 
pneumonia,  the  expectoration  acquires  the  appearance  of  prune- 
juice.  The  presence  of  considerable  quantities  of  fluid  in  the 
air-passages  frequently  gives  rise  to  loud  bulibling  rales  over  the 
chest,  and  the  plienomenon  has  also  lieen  designated  as  boiling  in 
the  chest.  If  expectoration  be  interfered  with  and  fluid  accumu- 
late in  the  trachea,  the  tracheal  rales  so  much  and  justly  feared 


CATARRHAL  INFLAMMATION  OF  THE  LUNGS  125 

develop,  and  which  so  frequently  appear  in  the  death-struggle. 
The  patient  suffering  from  pulmonary  edema  exhibits  signs  of 
objective  dyspnea,  which  are  manifested  in  accelerated  breathing, 
inspiratory  retraction  of  the  intercostal  spaces,  participation  of  the 
auxiliary  muscles  of  respiration,  cyanosis,  and,  in  consequence  of 
increasing  accumulation  of  carbon  dioxid  in  the  blood,  in  progres- 
sive stupor.  Pulmonary  edema  may  cause  death  within  a  short 
time  from  suffocation.  In  other  instances  it  persists  for  days,  or 
appears  and  disappears  repeatedly,  so  that  a  distinction  must  be 
made  between  acute,  chronic,  and  recurrent  pulmonary  edema. 

Prognosis. — The  prognosis  of  pulmonary  edema  is  serious  on 
all  occasions,  as  the  condition  is  often  dependent  upon  incurable 
disorders ;  and  besides,  whenever  the  edema  is  extensive,  there  is 
danger  of  death  from  suffocation. 

Treatment. — In  cases  of  pulmonary  edema  venesection  is 
indicated  as  an  important  measure   should  the  pulse  be  strong. 

Bandaging  of  fh'e  extremities  (by  means  of  rubber  tubing  or  compresses), 
in  order  to  diminish  the  flow  of  venous  blood  to  the  right  heart,  is  a  less 
reliable  procedure. 

In  addition,  stimulants  and  expectorants  should  be  employed 
to  increase  the  force  of  the  heart  and  to  clear  the  air-passages 
through  increased  expectoration ;   for  instance  : 


R  Powdered  digitalis-leaves, 

0.1 

(Ij  grains) ; 

Benzoic  acid. 

0.3 

(42-  grains)  ; 

Camphor, 

0.05 

(   f  grain) ; 

Sugar, 

0.5 

(7+  grains). - 

-M. 

Make  10  such  powders. 

Dose  :  1  powder  every  two  hours. 

The  administration  of  strong  wine  can  be  warmly  recommended. 
If  the  patients  are  unable  to  swallow,  camphorated  oil  may  be  in- 
jected subcutaneously  (15  minims  from  every  two  to  four  hours), 
and  dry  cups  and  mustard-plasters  or  alcoholic  frictions  to  th« 
chest  should  be  prescribed. 

CATARRHAL  INFLAMMATION  OF  THE  LUNGS 
(CATARRHAL  PNEUMONIA) » 

Htiology. — Catarrhal  pneumonia  is  always  a  secondary  dis- 
order, developing  in  the  sequence  of  preceding  inflammation  of  the 
smaller  bronchi — bronchiolitis.  The  disease  is,  therefore,  also 
designated  bronchopneumonia.  In  some  instances  the  inflammatory 
process  extends  directly  from  the  bronchial  mucous  membrane  to  the 
pulmonary  alveoli,  while  in  others  exciting  agents  of  inflammation 
are  aspirated  from  the  bronchial  tubes  into  the  pulmonary  alveoli, 
where  they  give  rise  to  secondary  inflammation.  Bacteria  are 
looked  upon  as  the  exciting  agents  of  inflammation,  although  vari- 
ous kinds  must  be  taken  into  consideration.    Frankel's  pneumonia- 


12()  CIRCULATORY  ORGANS 

cocci,  which  act  also  as  the  causative  agents  of  fibrinous  |3neu- 
raonia,  are  found  with  especial  frequency.  The  Streptococcus 
pyogenes  and  the  Staphylococcus  pyogenes  aureus  and  albus  are 
next  in  frequency  as  exciting  factors.  Friedliinder's  pneumococci 
have  also  been  described  as  causative  agents.  The  bacteria  named 
are  frequently  found  in  the  inflammatory  foci  in  pure  culture. 
Occasionally  other  specific  bacteria  are  found  accidentally;  as,  for 
instance,  diphtheria-bacilli.  A(/e  has  an  important  influence  upon 
the  development  of  catarrhal  pneumonia,  for  the  disease,  as  a  rule, 
attacks  cJi'ddren  or  the  (if/ed.  Diminislied  powers  of  resistance  on 
the  part  of  the  pulmonary  tissue,  smallness  of  caliber  of  the  bron- 
chial tubes  in  children,  and  deficient  activity  of  respiratory  move- 
ment in  the  aged  may  be  responsible  factors.  Delicate,  anemic, 
rachitic,  and  scrofulous  children  are  attacked  with  especial  fre- 
quency, as  well  as  those  compelled  to  live  in  over-crowded,  dusty 
rooms  with  an  insufficiency  of  light  and  of  air.  Catarrhal  pneu- 
monia occurs  with  especial  frequency  in  connection  witli  infectious 
diseases,  particularly  in  children  with  measles,  whooping-cough, 
and  di])htheria.  It  occurs  not  seldom  in  the  form  of  a  foreign- 
body  pneumonia  or  an  aspiration-pneumonia,  when  saliva,  food,  or 
fluid  gains  entrance  into  the  air-passages  and  reaches  the  alveoli 
of  the  lung.  Similar  conditions  are  observed  in  those  profoundly 
ill  (typhoid  fever),  in  the  debilitated  (carcinoma,  pulmonary  tuber- 
culosis), in  those  suffering  from  paralysis  of  the  muscles  of  deglu- 
tition (bulbar  paralysis,  pharyngeal  diphtheria),  and  in  C(mnection 
with  frequent  vomiting  and  regurgitation  ("carcinoma  of  the  esoph- 
agus). Inhalation  of  irritating  gases  must  also  be  considered  a  cause 
of  catarrhal  pneumonia. 

Anatomic  Alterations. — Areas  of  catarrhal  pneumonia  are 
almost  always  situated  at  the  surface  of  the  lung,  where  they  are 
conspicuous  for  their  dark-red  color  and  dense,  airless  consistency. 
On  section  no  air  can  be  expressed,  but  in  contradistinction  from 
atelectatic  areas,  which  are  not  rarely  found  side  by  side,  the 
pneumonic  areas  cannot  be  filled  with  air  from  the  bronchus,  and 
when  placed  in  water  they  sink  to  the  bottom.  Usually  numerous 
small  foci  of  inflammation  are  found,  which  exhibit  a  lobular 
arrangement ;  hence  the  name  lobular  or  insular  pneumonia. 
These  are  usually  especially  numerous  in  the  posterior  and  infe- 
rior portions  of  the  lungs.  At  times  they  coalesce  and  involve  the 
larger  portion  of  a  pulmonary  lobe.  With  comparative  frequency 
they  form  airless  bands,  which  begin  at  the  side  of  the  vertebral 
column  at  the  base  of  the  lung  and  extend  upward,  growing  grad- 
ually smaller  and  smaller.  Generally  the  inflammatory  areas  are 
situated  in  both  lungs.  The  lung  on  section  is  usually  smooth, 
although  granular  areas  of  inflammation  occur  which  to  a  certain 
degree  represent  a  transition  to  fibrinous  pneumonia.  Such  a 
transition  may  be  observed  also  microscopically.     Although  the 


CATARRHAL  INFLAMMATION  OF  THE  LUNGS  127 

majority  of  the  pulmonary  alveoli  are  filled  with  a  fluid  exudate 
consisting  of  blood-plasma,  desquamated  and  swollen  alveolar 
epithelial  and  round  cells,  fibrinous  coagula  can  be  detected  in 
others.  In  addition  to  atelectasis,  vicarious  pulmonary  emphysema 
is  not  rarely  found  in  association  with  catarrhal  pneumonia. 
Hyperemia,  hemorrhage,  and  fibrinous  deposits  upon  the  pleura  are 
also  common.  The  bronchial  glands  are  usually  enlarged  and 
hyperemic. 

Symptoms  and  Diagnosis. — It  is  often  extremely  difficult 
to  detect  the  presence  of  areas  of  catarrhal  inflammation  in  the 
lungs,  because,  by  reason  of  their  small  size,  they  are  not  acces- 
sible to  the  methods  of  physical  examination  and  are  often  con- 
cealed behind  the  manifestations  of  bronchial  catarrh.  Suspicion 
of  bronchopneumonia  should  always  be  aroused  when,  in  addition 
to  signs  of  bronchial  catarrh,  high  fever  (above  39°  C. — 102.2°  F.) 
persists  for  a  number  of  days.  In  the  diagnosis  auscultation  is  of 
especial  value,  frequently  disclosing  the  presence  of  bronchial 
breathing  and  ringing  rales  over  even  small  bronchopneumonic 
areas.  Duluess  on  percussion  can  be  expected  only  when  inflam- 
matory areas  have  coalesced  and  attain  a  circumference  of  five 
centimeters  and  a  thickness  of  two  centimeters.  Even  then  light 
percussion  is  necessary.  The  impaired  percussion-note  is  likely  to 
be  at  the  same  time  tympanitic,  as  the  tension  of  the  pulmonary 
tissue  is  diminished.  Usually  signs  of  disturbed  interchange  of  gases 
in  the  lungs  are  conspicuous,  as  manifested  by  accelerated  and 
frequently  gasping  and  moaning  respiration,  by  inspiratory  retrac- 
tion of  the  intercostal  spaces,  participation  of  the  auxiliary  muscles 
of  respiration,  and  cyanosis.  Often  there  is  distressing  cough; 
but  both  children  and  the  aged  are  given  to  swallowing  the 
sputum,  so  that  this  is  rarely  submitted  for  inspection.  It  is  then 
found  to  be  mucopurulent  and  free  from  peculiarity.  On  coughing 
and  on  deep  inspiration  pain  in  the  chest  is  frequent  in  conse- 
quence of  over-stretching  of  the  thoracic  muscles.  The  course 
of  catarrhal  ])neumonia  may  be  acute,  subacute,  or  chronic,  and 
extend  over  a  period  of  from  two  to  eight  weeks  and  more.  Not 
rarely  improvement  and  aggravation  alternate  with  each  other. 
Death  results  as  a  rule  in  consequence  of  asthenia  or  of  suffoca- 
tion. Not  rarely  progressive  stupor  develops  toward  the  close  of 
life  in  consequence  of  excessive  accumulation  of  carbon  dioxid  in 
the  blood  (carbon-dioxid  narcosis).  There  may  also  be  twitchings 
in  some  muscles  and  Cheyne-Stokes  breathing.  Should  the  dis- 
ease terminate  in  recovery,  this  takes  place  but  slowly  ;  a  crisis 
does  not  occur.  Further,  the  symptoms  of  bronchial  catarrh  fre- 
quently persist  for  a  long  time  after  those  of  the  pneumonia  have 
subsided.  Among  complicaUons  pleurisy,  pericarditis,  endocarditis, 
and  nephritis  may  be  mentioned.  At  times  miliary  tuberculosis 
develops  and  leads  to  a  fatal  termination. 


128  RESriRArORY  onaANS 

Prognosis. — Catarrlial  ])neuni<)nia  is  always  a  serious  affec- 
tion. In  sonic  epidemics  of  measles  and  whooping-cough  the 
largest  proportion  of  children  attacked  by  bronchopneumonia  die. 
The  more  extensive  the  inflammatory  process,  and  the  higher  the 
fever,  the  greater  is  the  danger  to  life. 

Treatment. — Individuals  with  catarrhal  pneumonia  should  be 
placed  ill  a  bright  and  airy  room,  which  can  be  ventilated  directly 
in  the  summer,  and  in  the  winter  through  an  adjacent  room.  The 
air  of  the  room  should  be  kept  moist  by  placing  a  solution  of 
sodium  chlorid  (0.7  per  cent.)  or  of  carbolic  acid  (2  per  cent.),  or 
creosote  or  oil  of  turpentine  (15  drops  on  the  surface  of  water),  in 
a  vessel  upon  a  stove  during  the  winter,  or  by  diffusing  one  of 
these  three  or  four  times  a  day  by  means  of  a  suital)le  spray- 
apparatus  during  the  summer.  In  addition  a  bath  at  a  tempera- 
ture of  from  26°  to  28°  R.  (90.5°  to  95°  F.)  and  of  from  fifteen  to 
thirty  minutes'  duration  should  be  given  at  nine  o'clock  in  the 
morning  and  at  four  o'clock  in  the  afternoon.  If  the  fever 
be  persistently  high,  an  effort  should  be  made  to  reduce  it  by 
means  of  a  cold  pack  or  phenacetin  (from  0.3  to  0.5 — 4|-  to  7^ 
grains).  Expectorants  should  be  prescribed  to  remove  the  secre- 
tion from  the  air-passages ;   for  instance  : 

R     Infusion  of  ipecacuanha-root,  0.3  :  100.0  (4V  grains  to  3}  fluidounces). 

Simple  sirup,  20.0  (5  fluidrams). — M. 

Dose :  5  c.c.  (1  teaspoonful)  every  two  hours. 

Should,  nevertheless,  excessive  accumulation  of  carbon  dioxid  in 
the  blood  or  of  secretion  in  the  bronchial  tubes  take  place,  a 
warm  bath  should  be  prescribed,  while  cold  water  is  poured  from 
a  considerable  height  upon  the  chest.  The  resulting  deep  respira- 
tory movements  will  then  help  to  clear  the  air-passages.  It  may 
also  be  useful  in  the  warm  bath  to  direct  a  stream  of  cold  water 
against  the  upper  portion  of  the  cervical  spine,  in  order  to  stimu- 
late the  respiratory  center  to  greater  activity.  After  recovery 
from  the  disease  a  sojourn  in  the  country  or  in  the  woods  should  be 
urgently  recommended. 

FIBRINOUS  INFLAMMATION  OF  THE  LUNGS 
(FIBRINOUS  PNEUMONIA). 

Ktiolog'y. — Fibrinous  pneumonia,  often  designated  also 
croupous  pn(>unionia,  is  an  exceedingly  common  infeciiov.s.  disease, 
by  which  almost  4  per  cent,  of  the  community  are  attacked 
annually.  The  pneumoniacoccus  of  Friinkel  acts  as  the  carrier 
of  the  infection,  although  it  has  been  maintained  that  in  a  small 
number  of  insUuices  other  bacteria  also  induce  the  disease. 

The  pneumoniacocci  of  Frankel  are  somewhat  long  structures,  in  shape 
resembling  a  candle-flame,  which  are  surrounded  by  a  bright  capsule  and 


FIBRINOUS  INFLAMBIATION  OF  THE  LUNGS 


129 


are  arranged  usually  in  pairs,  but  frequently  also  in  groups  of  several  within 
a  common  capsule'(Fig.  22).  They  have,  therefore,  also  been  designated 
diplococcus  jmeumo/iice  s.  lanceolatus.  They  occur  also  in  the  saliva  of 
healthy  individuals,  and  cause  death  in  rabbits,  with  septic  manifestations, 
so  that  they  have  also  been  designated  sputum-cocci  or  cocci  of  sputum- 


FiG.  22.— Pneumoniacocci  of  Frankel  from   pneumonic  sputum.     Gentian-violet  stain; 
oil-immersion ;  magnified  1000  times  (personal  observation,  Zurich  clinic). 


septicemia.  It  is  noteworthy  that,  in  contradistinction  from  the  pneumonia- 
cocci  of  Friedlander,  which  resemble  them,  and  which  for  a  time  were 
erroneously  considered  as  the  exciting  agents  of  fibrinous  pneumonia,  they 
can  be  stained  by  Gram's  method. 

Although  infection  with  the  pneumoniacocci  of  Frankel  is 
essential  for  the  development  of  fibrinous  pneumonia,  there  are 
certain  conditions  that  favor  infection  of  the  lungs — so-called  con- 
tributory causes  of  the  infection.  Among  these  exposure  to  cold 
occupies  the  most  conspicuous  place,  while  traumatism  and  pre- 
ceding infectious  disease  are  less  commonly  operative.  In  over- 
crowded barracks,  prisons,  and  reformatories,  extensive  epidemics 
of  pneumonia  have  at  times  occurred,  obviously  because  the  air 
was  contaminated  and  filled  with  pneumoniacocci.  Transmission 
of  the  disease  from  one  person  to  another  or  through  the  intermedia- 
tion of  a  third  person  has  also  been  observed.  Frequently,  how- 
ever, no  contributory  cause  can  be  elicited,  and  the  condition  is 
then  designated  a  genuine  or  pjrimary  fibrinous  pneumonia.  Like 
most  infectious  diseases,  fibrinous  pneumonia  also  occurs  sporadic- 
ally and  epidemically.  Epidemics  occur  especially  in  the  spring 
months,  from  March  to  May.  Experience  has  shown  that  men 
are  attacked  more  commonly  than  women.  Individuals  debilitated 
by  disease,  advanced  age,  or  alcoholism  exhibit  a  more  marked 
predisposition  to  the  disease  than  others.     The  disorder  spares  no 

9 


130  RESriRATORY  ORGANS 

period  of  life,  and  not  rarely  attacks  chiklron.  There  is  an 
undeniable  tendency  to  repeated  rdtachs,  so  that  some  persons  pass 
through  more  than  twenty  attacks  of  fil)rinous  pneumonia  in  the 
course  of  their  lives. 

Anatomic  Alterations. — The  inflammatory  alterations  of 
fibrinous  pneumDuia  do  not  occur  in  numerous  lobular  areas  like 
those  of  catarrhal  pneumonia,  but,  as  a  rule,  involve  the  entire 
lobe  of  a  lung,  or  still  more,  whence  the  designation  lobar  pneu- 
monia. It  is  customary  to  distinguish  several  stages  of  the  in- 
flammatory process,  and  to  designate  these  congestion,  hepatization, 
and  resolution. 

In  the  stage  of  inflammatory  congestion  the  pulmonary  capillaries 
are  dilated  and  tortuous.  Blood-plasma  is  thrown  out  into  the 
pulmonary  alveoli ;  at  the  same  time  round  cells  and  also  red 
blood-corpuscles  accumulate  in  the  alveoli,  while  the  alveolar  epi- 
thelial cells  become  detached  and  are  in  part  desquamated. 

In.  the  stage  of  hepatization  the  lung  presents  a  characteristic 
appearance.  On  removal  of  the  organs  it  is  noteworthy  that 
in  the  area  of  inflammation  the  impression  of  the  ribs  upon  the 
surface  of  the  lungs  is  visible,  because  the  lungs  have  obviously 
increased  in  volume.  The  pleura  probably  is  unexceptionally 
clouded,  and  covered  with  fibrinous  membrane,  if,  as  is  the  rule, 
the  inflammation  has  extended  to  the  surface  of  the  lungs.  The 
condition  is  thus  usually  one  of  fibrinous  pleuropneumonia.  On 
palpation  the  lung  yields  the  impression  of  an  airless,  solid  struct- 
ure. On  section  its  granular  surface  is  striking,  suggesting  the 
appearance  of  a  section  of  liver,  whence  the  name  hepatization. 
The  granular  condition  is  due  to  coagulation  of  the  primarily 
fluid  alveolar  exudate.  For  this  reason  the  hepatized  portions 
of  lung  present  in  the  aged  and  in  emphysematous  patients  with 
large  pulmonary  alveoli  a  coarsely  granular,  and  in  children 
Avith  small  pulmonary  alveoli  a  finely  granular,  appearance.  The 
mucous  membrane  of  the  supplying  bronchial  tubes  is  reddened 
and  swollen,  and  the  fibrinous  inflammation  has  not  rarely  ex- 
tended to  the  smaller  bronchial  tubes,  so  that  they  contain  bron- 
chial casts  or  fibrinous  coagula.  Less  commonly  the  larger  bron- 
chial tubes  also  are  filled  with  fibrinous  casts,  and  the  condition 
is  then  designated  ntassive  pneumonia.  At  the  outset  the  hepa- 
tized pulmonary  tissue  exhibits  a  red  color — stage  of  red  hepati- 
zation. The  more,  however,  the  over-distention  of  the  pulmonary 
blood-vessels  subsides  the  more  does  the  tissue  present  a  grayish 
color — star/e  of  gray  hep(di~ation,  which  ultimately  gives  place  to 
a  yellow  color — stage  of  yellou-  hepatization,  as  soon  as  active  fatty 
degeneration  takes  place  in  the  inflammatory  products.  As  a 
rule,  the  inflammation  develops  in  diflerent  portions  of  the  lungs 
at  different  times,  so  that  generally  various  stages  of  hepatization 
are  present  side  by  side.     In  consequence  the  lung  acquires  a 


FIBRINOUS  INFLAMMATION  OF  THE  LUNGS  131 

mottled  appearance,  which  has  not  inappropriately  been  desig- 
nated as  marbled  or  granite-like.  This  appearance  is  especially 
marked  when  the  diseased  lung  contains  a  good  deal  of  melanin. 
In  the  stage  of  resolution  liquefaction  of  the  coagulated  alveolar 
exudate  takes  place  in  conjunction  with  mucoid  and  fatty  degen- 
eration, perhaps  also  in  consequence  of  digestion  by  bacteria,  the 
liquefied  masses  are  expectorated  or  absorbed,  the  pulmonary 
alveoli  again  receive  air,  and  gradually  the  lung  resumes  ita 
normal  appearance. 

On  microscopic  examination  of  the  lungs  during  tlie  stage  of  hepatizatiorr 
the  pulmonary  alveoli  will  be  found  filled  with  a  fibrinous  network,  in  the' 
midst  of  which  lie  round  cells,  red  blood- corpuscles,  and  alveolar  epithelial 
cells.  The  fibrinous  network  is  especially  dense  at  the  periphery  of  the 
pulmonary  alveoli,  while  the  cells  are  more  numerous  toward  the  center 
of  the  alveoli.  Pneumoniacocci  are  present,  partly  free,  partly  enclosed  in 
cells.  In  the  stage  of  resolution  the  fibrinous  network  undergoes  disinte- 
gration into  small  granules,  and  active  fatty  degeneration  takes  place  in  the 
round  cells  and  the  alveolar  epithelium. 

Fibrinous  pneumonia  occurs  most  frequently  in  the  lower  lobe, 
particularly  on  the  right  side,  and  least  commonly  in  the  right 
middle  lobe.  At  times  inflammatory  foci  are  present  in  both 
lungs — pneumonia  jibrinosa  dwplex.  If  under  such  conditions 
corresponding  lobes  are  not  involved  on  both  sides,  for  instance, 
the  right  lower  and  the  left  upper  lobe,  the  condition  is  designated 
pneumonia  jibrinosa  cruciata.  If  all  the  lobes  of  one  lung  are 
involved,  the  condition  is  known  as  pneumonia  totalis. 

The  situation  of  pneumonia  most  commonly  in  the  lower  lobe  of  the 
right  lung  is  explained  by  the  fact  that  foreign  bodies  (pneumoniacocci) 
more  readily  enter  this  lung  through  its  larger  bronchus,  and  on  account 
of  its  greater  aspirating  force,  and  that  these  by  reason  of  their  weight 
readily  find  their  way  into  the  lower  lobe. 

Persons  dead  of  fibrinous  pneumonia  usually  exhibit  signs  of 
suffocation  and  of  constitutional  infection.  The  right  heart  and 
the  veins  are  generally  filled  with  blood,  the  heart  with  ham-fat 
clot  and  masses  of  coagula,  while  the  left  heart  contains  no  blood. 
The  muscles  of  the  trunk  and  the  extremities  appear  dry  and  of 
the  color  of  ham,  and  exhibit,  on  microscopic  examination,  gran- 
ular turbidity,  fatty  and  vitreous  degeneration  of  the  muscle-fibers. 
Similar  histologic  alterations  are  present  in  the  fibers  of  the  heart- 
muscle.  The  liver-cells,  the  parenchymatous  cells  of  the  gastric 
and  intestinal  glands,  the  epithelial  cells  of  the  uriniferous  tub- 
ules, and  the  parenchymatous  cells  of  the  pancreas  exhibit  gran- 
ular cloudiness  and  fatty  degeneration.  Swelling  and  hyperemia 
of  the  bronchial  glands  are  constant  manifestations  of  fibrinous 
pneumonia,  and  result  from  absorption  of  the  inflammatory  agents 
from  the  diseased  lung.  The  spleen  is  frequently  but  not  con- 
stantly enlarged,  and  of  diminished  consistency  (acute  infection- 
spleen). 


132 


EESPrn.  1  TOR  Y  OR  a  A  NS 


Symptoms. — Fil)rin()ns  pncuimonia  belongs  to  the  class  of 
cijclic  acute  j'c/ji-i/e  iiijcctioim  diseases,  as  it  pursues  a  typical  course, 
and  terminates  usually  within  two  weeks,  with  manifestations  of 
a  crisis.  Two  groups  of  plionomona  must  be  distinguished  :  In 
the  first  place,  the  local  manifestations,  and  in  the  second  tiie  feb- 
rile constitutional  manifestations.  The  hitter  are  probably  due  to 
the  entrance  into  the  circulation  of  toxins  generated  by  the  pneu- 
moniacocci.  The  period  of  incubation — that  is,  the  interval  be- 
tween the  occurrence  of  infection  and  the  development  of  the  first 
symptoms  of  the  disease — apj^ears  in  many  instances  to  be  only  a 
few  hours,  although  it  may  be  from  two  to  four  days,  and  at  times 


Fig.  23.— Typical  tciiipLTatnre-curvo  <if  tiliriiious  pneumonia  in  a  mau  cigbteen  years  old 
(personal  observation,  Zurich  clinie  . 

perhaps  still  longer.  As  a  rule,  the  disease  sets  in  suddenly^  Avith 
a  rifjor,  which  may  occur  while  the  patient  is  engaged  at  work  or 
is  sound  asleep.  This  is  followed  bv  a  continued  fever,  the  tem- 
perature rising  to  39°  or  40°  C.  (102.2°  or  104°  F.)  and 
above.  The  pulse  is  accelerated,  full,  and  often  dicrotic.  The 
face  is  vividlv  flushed.  The  tongue  is  covered  with  a  whitish  or 
grayish  coating.  "While  the  thirst  is  greatly  increased,  the  appe- 
tite is  entirely  wanting.  The  urine  is  voided  in  small  amounts, 
is  highly  concentrated,  and  not  rarely  contains  small  amounts  of 
albumin  (febrile  albuminuria).  After  from  five  to  seven  days, 
at  times,  however,  also  earlier  or  later,  ]irofuse  sweating  suddenly 
appears  upon  the  skin,  most  frequently  during  the  evening  hours. 
The  patient  falls  into  a  deep,  quiet  sleep,  and  in  the  course  of 


FIBRINOUS  INFLAMMATION  OF  THE  LUNGS  133 

twelve  hours  is  free  from  fever  (Fig.  23).  Temperature  and 
pulse-rate  are  often  even  subnormal  immediately  after  tlie  crisis. 
The  urine  frequently  deposits  a  precipitate  of  urates. 

At  times  deviations  take  place  in  the  course  of  the  crisis.  Thus  deferves- 
cence occasionally  occupies  more  than  twenty-four  hours — p7'otracted  crisis  ;  or 
during  defervescence  renewed  elevation  of  bodily  temperature  takes  place — 
interrupted  crisis.  Sometimes  disturbing  symptoms  appear  shortly  before  the 
advent  of  the  crisis,  such  as  chill,  delirium,  and  hyperpyrexia — critical  per- 
turbation.    This  is,  however,  without  evil  significance. 

The  constitutional  and  the  local  symptoms  of  fibrinous  pneu- 
monia exhibit  a  certain  independence  of  one  another,  for  the  former 
set  in  earlier,  and  also  disappear  earlier,  than  the  latter.  Among 
the  first  local  symptoms  are  often  a  stitch  in  the  diseased  side  of 
the  chest,  cough,  and  expectoration.  The  further  phenomena  vary 
with  the  stage  of  the  inflammatory  process. 

In  the  stage  of  congestion  the  percussion-note  over  the  inflamma- 
tory area  is  tympanitic,  and  on  gentle  percussion  it  is  also  slightly 
impaired,  because  the  tension  of  the  pulmonary  tissue  is  diminished 
and  the  lung  has  been  deprived  of  air.  On  auscultation  crepitant 
or  crackling  (fine  moist)  rales  are  heard  during  inspiration  as  the 
alveolar  walls  separate  from  their  viscid  contents.  The  expectora- 
tion is  usually  mucous,  vitreous,  and  intermixed  with  spots  and 
streaks  of  blood. 

In  the  stage  of  hepatization  vocal  fremitus  is  increased.  The 
percussion-note  is  greatly  impaired,  and  on  auscultation  bronchial 
breathing  is  heard.  All  of  these  phenomena  depend  upon  the 
absence  of  air  from  the  pulmonary  tissue.  Should  rales  be 
audible  in  the  inflammatory  area,  these  acquire  a  ringing  (con- 
sonating)  character.  Bronchojihony  is  increased,  and  at  times 
egophony  is  present.  Rusty  sputum,  sputum  rubiginosmn,  is  espe- 
cially significant  from  a  diagnostic  point  of  view,  indicating  with 
certainty  the  stage  of  red  hepatization  of  the  lungs.  As  its 
name  implies,  the  sputum  exhibits  the  brownish-red  color  of  iron- 
rust,  and  also  a  vitreous  transparency,  is  but  little  frothy,  and  so 
viscid  as  to  be  comparable  with  thick  gelatin.  On  inverting  the 
vessel  the  sputum  remains  adherent  to  its  sides ;  it  can  almost 
be  cut.  On  microscopic  examination,  in  addition  to  round  cells 
and  desquamated  alveolar  epithelial  cells,  red  blood-corpuscles  are 
found,  which  are  usually  distended  so  as  to  be  biconcave,  and  to 
the  alteration  in  whose  hemoglobin  the  rusty  color  is  due.  In 
preparations  stained  with  aniline  colors  the  pneumoniacocci  of 
Frankel  can  be  demonstrated.  Frequently  the  sputum  contains 
rolled-up  grayish  or  whitish  filaments,  often  streaked  with  blood, 
which  on  agitation  in  water  resolve  themselves  into  delicately 
branched  /?6rmoi(.s  bronchial  coagula,  and  which  indicate  participa- 
tion of  the  smaller  bronchial  tubes  in  the  fibrinous  inflammatory 
process  in  the  pulmonary  alveoli.     As  fibrinous  pneumonia  ap- 


134  RESPIRATORY  ORGANS 

preaches  the  stage  of  resolution  the  sputum  acquires  a  lemon- 
yellow  or  saffron-yellow  hue,  spuftan  croceum,  and  with  the 
termination  of  the  inflammatory  process  it  acquires  the  appear- 
ance of  colorless  mucous  expectoration. 

In  the  stage  of  resolution  the  physical  alterations  in  the  lungs 
resemble  those  present  in  the  stage  of  congestion.  The  dulness 
grows  gradually  less  and  less,  and  the  percussion-note  becomes 
at  first  tympanitic,  then  clear.  The  respiratory  murmur  again 
resumes  its  vesicular  character,  and,  above  all,  crepitant  rales, 
rhonchus  crepitans  redux  s.  crepitatio  redux,  are  audible  in  abun- 
dance, and  which  disappear  again  only  when  the  pulmonary  alveoli 
no  longer  contain  fluid  exudate.  Patients  with  pneumonia  usually 
exhibit  a  reddened  and  often  also  a  cyanotic  hue  of  the  face.  At 
times  the  redness  is  more  actively  developed  upon  the  side  of  the 
face  corresponding  to  that  of  the  diseased  lung.  Generally  the 
patient  assumes  an  elevated  dorsal  decubitus.  Recumbency  upon 
the  diseased  side  is,  as  a  rule,  avoided  in  consequence  of  the  pain 
induced  by  pressure.  Respiration  is  accelerated,  partly  in  conse- 
quence of  the  fever  and  partly  in  consequence  of  diminished 
participation  of  the  diseased  portion  of  the  lung  iu  the  respiratory 
act.  The  pidse  is  generally  accelerated  out  of  proportion  to  the 
febrile  elevation  of  temperature.  This  is  believed  to  be  due  to 
the  increased  blood-pressure  in  the  distribution  of  the  pulmonary 
artery.  The  respiratory  movements  appear  less  active  and  retarded 
upon  the  diseased  side,  and  often  jerky  in  consequence  of  pleuritic 
pains.     Speech  is  usually  interrupted  at  short  intervals  and  jerky. 

As  in  most  infectious  diseases,  so  also  in  fibrinous  pneumonia  a 
distinction  must  be  made  between  anomalies,  complications,  and 
sequelce.  The  anomalies  of  pneumonia  depend  at  times  upon  the 
severity  of  the  local  and  constitutional  infection,  and  at  times  upon 
individual  conditions.  The  abortive,  the  ephemeral,  and  the  afebrile 
forms  of  pneumonia  must  be  considered  as  instances  of  especially 
mild  local  and  constitutional  infection.  In  cases  of  abortive  pneur- 
monia  the  inflammatory  process  advances  only  to  the  stage  of  con- 
gestion and  then  undergoes  involution.  Ephemeral  or  one-day 
ptneumonia  passes  through  all  the  stages  of  tlie  inflammation,  but 
the  fever  subsides  by  crisis  within  twenty-four  hours.  Afebrile 
pneumonia,  notwithstanding  well-developed  local  manifestations 
and  characteristic  expectoration,  is  a  rare  condition. 

The  protracted,  the  progressive,  and  the  erratic  forms  of  pneu- 
monia must  be  looked  upon  as  instances  of  severe  local  infection. 
Protracted  prneumonia  persists  at  times,  with  fever,  for  from  four 
to  six  weeks,  and  generally  terminates  with  gradual  defervescence 
(lysis).  At  times  it  is  associated  with  septic  manifestations  (mul- 
tiple articular  swellings  and  the  like).  Progressive  pneumonia  is 
characterized  by  extension  of  the  inflammation  from  one  lobe  to  an 
adjacent  one,  so  that  finally  an  entire  lobe  is  involved  from  an 


FIBRINOUS  INFLAMMATION  OF  THE  LUNGS  135 

originally  small  area.  Erratic  or  u-andering  pneurnonia  is  attended 
with  the  formation  of  inflammatory  foci  that  develop  successively 
now  in  one,  then  in  another  lobe,  but  separated  from  one  another 
by  a  considerable  distance.  Under  such  conditions  the  disease 
may  persist  for  many  weeks.  Not  rarely  it  is  attended  with  mul- 
tiple articular  swellings. 

Constitutional  infection  of  especial  severity  attends  asthenie 
pneumonia,  which  has  also  been  designated  typhoid,  putrid,  or 
malignant  pneumonia.  The  patients  attract  attention  from  the 
outset  on  account  of  the  marked  asthenia,  and,  from  the  presence 
of  delirium,  of  sordes  on  the  lips  and  the  gums,  dryness  of  the 
tongue,  distention  of  the  abdomen,  enlarged  spleen,  and  diarrhea, 
are  suggestive  of  the  clinical  picture  of  typhoid  fever.  At  times 
slight  jaundice  develops,  Avhence  the  name  of  bilious  pneumonia. 
The  sputum  frequently  is  noteworthy  on  account  of  its  bloody 
appearance.  Death  often  occurs  from  asthenia.  In  many  epidemics 
the  asthenic  varieties  of  pneumonia  predominate,  and  are  respon- 
sible for  the  high  mortality.  The  asthenic  character  of  fibrinous 
pneumonia  may,  in  addition  to  the  severity  of  the  general  infec- 
tion, be  further  dependent  upon  individual  conditions.  This  may 
find  expression  particularly  in  the  fbrinous  pmeumonia  of  drunkards 
and  the  aged.  Under  such  circumstances  the  condition  has  been 
spoken  of  as  a  secondary  or  individual  asthenic  jjneumonia. 
Drunkards  and  the  aged  display  but  little  resistance  to  infection 
with  pneumoniacocci,  are  frequently  attacked  by  fibrinous  pneu- 
monia, and  often  lose  their  lives  in  consequence.  The  danger 
resides  especially  in  paralysis  of  the  heart,  which  sets  in  early  and 
often  with  surprising  rapidity. 

The  fibrinous  pneumonia  of  children  not  rarely  exhibits  the 
peculiarity  that  it  sets  in  with  vomiting  and  eclamptic  convulsions 
instead  of  with  a  chill.  As  in  the  case  of  the  aged,  children 
generally  do  not  expectorate,  but  usually  swallow  the  sputum. 
The  fever  often  terminates  gradually,  by  lysis. 

The  recurring  and  the  intermittent  forms  of  pneumonia  may  be 
mentioned  as  special  anomalous  forms.  The  former  is  character- 
ized by  the  renewed  appearance  of  fever  and  of  inflammation  of 
the  lung,  the  latter  involving  the  area  first  attacked  or  others ; 
Mhile  the  intermittent  variety  appears  in  malarious  regions  under 
the  influence  of  the  malarial  parasites  (plasmodia),  and  is  charac- 
terized by  regularly  recurrent  febrile  movement  and  inflammatory 
manifestations.  It  is  further  distinctive  that  intermittent  pneu- 
monia, which  is  by  no  means  unattended  with  danger,  can  be 
cured  by  administration  of  quinin. 

Among  the  complications  of  fibrinous  pneumonia  fibrinous 
pleurisy  and  bronchial  catarrh  are  observed  so  constantly  that 
they  can  scarcely  be  considered  complications.  A  pleuritic  fric- 
tion-murmur is  heard  not  at  all  frequently,  and  the  occurrence  of 


136  RESPIRATORY  ORGANS 

severe  pain  in  breathing  and  on  coughing  must  often  be  sufficient 
to  indicate  the  existence  of  pleurisy.  By  no  means  rarely  pleurisy 
with  effusion  occurs,  and  the  exudate  is  more  frequently  serous 
than  purulent.  The  exciting  agents  of  the  inflammation  are  at 
times  pneumoniacocci,  at  times  pyogenic  cocci.  The  same  state- 
ment is  applicable  to  the  remaining  inflammatory  complications, 
and  pneumoniacocci  have  been  frequently  found  in  different 
organs,  and  also  in  the  blood. 

One  of  the  most  common  and  most  serious  complications  is 
indicated  by  the  occurrence  o{ prune-j a  ice-like  exjjectorat ion,  which, 
in  contradistinction  from  rusty-colored  sputum,  is  diffluent,  frothy, 
and  dark  blackish-rcd,  and  in  appearance  is  suggestive  of  prune- 
juice.  The  patients  at  the  same  time  exhibit  marked  cyanosis, 
accelerated  and  embarrassed  breathing,  and  tracheal  rales.  On 
auscultation  of  the  lungs  small  moist  rales  are  heard  over  a  wide 
distribution,  because  the  .alveoli  are  filled  with  serous  fluid. 
Usually  the  condition  is  probably  one  of  hypostatic  edema,  which 
develops  in  consequence  of  enfeeblement  of  the  left  ventricle. 
The  more  vigorous  right  ventricle  fills  the  lungs  with  blood, 
which,  by  reason  of  the  weakness  of  the  left  heart,  does  not  find 
sufficiently  ready  access  to  the  left  auricle.  The  danger  of  inter- 
current pulmonary  edema  is  especially  great  in  persons  with  an 
already  enfeebled  heart  (as,  for  instance,  in  the  aged  and  in  drunk- 
ards), and  the  rapidity  Avith  which  the  condition  develops  and 
terminates  life  is  often  surprising. 

Inflammatory  altei-aiions  of  the  endocardium,  the  myocardium, 
or  the  pericardium  occur  occasionally,  but  are  on  the  whole  of 
minor  significance.  The  same  statement  applies  to  gastric  and 
intestinal  manifestations.  At  times  jaundice  appears,  and  the  elimi- 
nation of  biliary  coloring-matter  in  the  expectoration  gives  this 
a  grass-green  appearance. 

Albuminuria  and  tube-casts  in  the  urine  are  common,  while 
hematuria  and  other  signs  of  acute  nephritis  are  less  common. 
The  rapidity  with  which  these  phenomena  disappear  is  at  times 
remarkal)le,  even  when  no  noteworthy  changes  have  taken  place 
in  the  course  of  the  fever  and  in  the  local  phenomena  in  the  lungs. 

Not  rarely  delirium  occurs  in  cases  of  fibrinous  pneumonia, 
and  with  especial  frequency  in  children  and  in  drunkards.  The 
greater  the  elevation  of  temperature  the  more  likely  is  delirium 
to  occur,  although  tliis  may  l)e  present  also  when  the  fever  is  of 
lesser  degree,  so  that  it  must  then  be  looked  upon  as  a  result 
of  the  general  infection.  At  times  purulent  cerebrospinal  menin- 
gitis develops,  especially  at  such  times  as  epidemic  cerebros])inal 
meningitis  ])revails  in  association  with  pneumonia  or  has  prevailed 
shortly  before.  Often  it  is  impossible  to  recognize  the  disease 
because  characteristic  symptoms  (rigidity  of  the  neck,  inequality 
of  the  pupils)  are  wanting. 


FIBRINOUS  INFLAMMATION  OF  THE  LUNGS  137 

Herpes  is  an  unusaully  common  occurrence.  It  is  most  fre- 
quently situated  upon  the  lips  at  one  side  and  less  commonly  on 
.both  sides.  Multiple  articular  swellings  are  suggestive  of  septic 
states,  as  is  also  purulent  parotiditis. 

Among  the  sequelce  of  fibrinous  pneumonia  diseases  of  the 
lungs  themselves  are  by  far  the  most  common.  Among  these 
pulmonary  abscess,  pulmonary  gangrene,  pulmonary  contraction, 
and  pulmonary  tuberculosis  may  be  especially  mentioned. 

Occasionally  psijchopathi/,  neuritis,  and  poliomyelitis  have  been  observed 
in  the  sequence  of  pneumonia. 

Diagnosis. — In  the  recognition  of  fibrinous  pneumonia  the 
rusty-colored  sputum  is  of  great  diagnostic  significance.  In  cases 
of  central  pneumonia  it  is  almost  the  only  certain  sign.  The  saffron- 
colored  and  the  prune-juice-like  expectoration  also  are  extremely 
valuable  phenomena  in  reaching  a  decision  as  to  the  course  of  the 
disease.  Besides,  the  typical  temperature-curve  (continued  fever, 
beginning  with  a  chill,  and  usually  terminating  between  the  fifth 
and  the  ninth  day  by  crisis)  at  times,  but  usually  subsequently, 
clears  up  the  nature  of  obscure  febrile  disease.  If  doubt  arise 
whether  a  case  be  one  of  fibrinous  pneumonia  or  of  typhoid  fever, 
it  should  be  recalled  that  the  presence  of  herpes  is  opposed  to 
and  that  of  roseola  is  in  favor  of  the  existence  of  typhoid  fever. 
A  positive  result  with  the  Widal  reaction  and  the  demonstration 
of  typhoid-bacilli  in  the  stools,  the  urine,  or  the  blood  would  be 
decisive  for  typhoid  fever.  Peripheral  fibrinous  pneumonia  is  read- 
ily recognizable  from  the  manifestations  of  acute  infiltration  of  the 
lungs  (dulness,  bronchial  breathing,  increased  vocal  fremitus,  and 
rales).  Although  pleurisy  with  eiFusion  gives  rise  to  dulness  on 
percussion,  the  vocal  fremitus  is  diminished,  and  bronchial  breath- 
ing induced  by  compression  of  the  lung  appears  enfeebled.  The 
vocal  fremitus  is  diminished  only  in  cases  of  massive  pneumonia, 
as  in  pleurisy,  because  the  occlusion  of  the  bronchial  tubes  with 
fibrinous  coagula  prevents  the  transmission  of  the  voice-waves 
from  the  larynx  to  the  thoracic  w^all.  Nevertheless,  in  the  pres- 
ence of  pleurisy  the  adjacent  organs  are  frequently  displaced ;  and 
if  effusion  takes  place  into  the  left  pleural  cavity,  the  semilunar 
space  is  diminished.  It  is  noteworthy  that  pleurisy  but  rarely  sets 
in  with  a  chill,  and  pursues  its  course  with  continued  fever.  As 
opposed  to  pleurisy  with  eifusion  would  be  dulness  confined  to  the 
upper  portion  of  the  thorax,  diminishing  in  intensity  from  above 
downward,  and  exhibiting  a  most  irregular  upper  boundary.  In 
doubtful  cases  exploratory  puncture  will  clear  up  the  diagnosis. 
Bacteriologic  examination  of  the  sputum,  for  the  presence  of  pneu- 
moniacocci  has  little  bearing  upon  the  diagnosis,  because  these 
organisms  are  also  found  in  the  saliva  of  healthy  persons. 

It  is  further  important  correctly  to  localize  diagnosed  pneumonic  areas. 
On  the  right  anteriorly  the  entire  area  from  the  apex  to  the  fourth  rib  cor- 


138  RESPIRATORY  ORGANS 

responds  to  the  upper  lobe,  that  between  the  fourth  and  the  sixth  rib  to 
the  middle  lobe.  On  the  left  only  the  upper  lobe  is  accessible  anteriorly. 
Posteriorly,  all  alterations  down  to  the  level  of  the  spine  of  the  scapula 
must  be  referred  to  the  upper  lobe,  and  below  this  level  to  the  lower  lobe 
on  both  the  right  and  the  left  side.  Laterally,  the  fourth  rib  on  either  side 
constitutes  the  boundary  between  the  upper  and  the  lower  lobes.  On  the 
right  side,  however,  a  process  of  the  middle  lobe  is  situated  between  the 
sixth  and  seventh  ribs.  Further,  variations  in  the  limits  named  occur  to 
the  extent  of  an  intercostal  space  in  consequence  of  increase  in  size  of  a 
diseased  pulmonary  lobe. 

Prognosis. — The  prognosis  of  fibrinous  pneumonia  depends 
upon  the  age,  the  constitution,  the  extent,  and  the  seat  of  the  in- 
flammation, the  severity  of  the  general  infection,  and  the  complica- 
tions. Military  surgeons  report  that  they  rarely  see  soldiers  die 
in  consequence  of  fibrinous  pneumonia,  because  the  patients  are 
robust  and  youthful  individual.  On  the  other  hand,  the  disease 
is  an  unusually  serious  onean  the  aged,  as  the  majority  succumb. 
Fibrinous  pneumonia  is  also  a  serious  disorder  in  children.  Of 
especial  importance  in  its  bearing  upon  the  course  of  the  disease 
is  the  condition  of  the  heart.  All  persons  with  enfeebled  and  read- 
ily exhausted  heart-rauscle  readily  perish  in  consequence  of  pul- 
monary edema  or  cardiac  paralysis.  Excessive  demands  are  made 
upon  the  functional  activity  of  the  heart-muscle  by  reason  of  the 
fever  (augmented  contraction),  and  from  increased  blood-pressure 
in  the  pulmonary  circulation  (from  compression  of  the  pulmonary 
capillaries  within  the  inflammatory  area),  to  which  the  organ  is 
unable  to  respond.  In  the  aged  also  the  frequency  of  death  fol- 
lowing pneumonia  depends  principally  upon  the  cardiac  enfeeble- 
mcnt.  The  same  statement  is  applicaV)le  to  drunkards,  to  indi- 
viduals with  kyphoscoliosis,  obesity,  heart-disease,  and  to  pregnant 
Avomen.  Similar  conditions  may  arise  in  the  absence  of  demon- 
strable anatomic  alterations  in  the  heart-muscle.  At  times  the 
continuance  of  life  is  rendered  impossible  from  the  extent  of  lung- 
tissue  involved  in  the  inflammatory  process,  so  that  suffocation 
results.  Fibrinous  pneumonia  of  the  vpper  lobe  is  not  without 
justice  considered  more  unfavorable,  because  it  undergoes  absorp- 
tion more  slowly  and  less  completely,  and  is  not  rarely  followed 
by  pulmonary  tuberculosis.  The  significance  of  the  general  infec- 
tion is  apparent  from  the  seriousness  of  ]irimarily  asthenic  pneu- 
monia. To  indicate  the  bearing  of  compHcationa  it  should  suffice 
to  point  out  that  an  intercurrent  jiurnlent  meningitis  renders  the 
prognosis  unfavorable. 

Treatment. — No  specific  remedy  for  fibrinous  pneumonia  is 
yet  known.  Treatment  with  blood-serum  has  been  attempted  of 
late,  but  this  has  scarcely  yet  led  to  encouraging  practical  results. 
In  cases  of  fibrinous  pneumonia  in  young,  robust  individuals 
expectant  treatment  may  be  pursued  as  long  as  serious  complica- 
tions do  not  arise.     When  possible,  the  patient  should  occupy  for 


INTERSTITIAL  PNEUMONIA  139 

himself  a  quiet  and  capacious  room,  whose  temperature  should  be 
kept  at  14°  R.  (63.5°  F.).  The  air  should  be  kept  moist  by 
means  of  vessels  of  water,  which  in  winter  are  placed  in  the 
stove-pipe  or  upon  the  stove,  or  water  is  vaporized  by  means  of  a 
Siegle  steam-apparatus,  or  a  solution  of  carbolic  acid  (2  per  cent.) 
is  sprayed  throughout  the  room  three  or  four  times  daily.  Ade- 
quate ventilation  may  be  obtained  by  opening  the  windows  in  an 
adjoining  room.  The  patient  should  be  given  only  a  liquid  diet, 
especially  boiled  milk,  milk  with  a  little  coffee  or  a  little  tea, 
bouillon  with  egg,  and,  if  thirst  be  marked,  lemonade  or  white 
wine,  diluted  half  with  water.  Symptomatic  treatment  will  be 
resorted  to  when  individual  symptoms  are  distressing  or  threat- 
ening. Expectorants  are  frequently  employed  when  an  abundance 
of  moist  rales  indicate  the  presence  of  fluid  secretion  in  the  air- 
passages  ;  for  instance  : 

R  Infusion  of  ipecacuanha-root,         0.5  :  180  (7J  grains  to  5|  fluidounces)  ; 

Simple  sirup,  20.0  (5  fluidrams). — M. 

Dose:  15  CO.  (1  tablespoon ful)  every  two  hours. 

For  severe  pain  dry  or  ivet  cups  may  be  employed.  If  signs  of 
cardiac  weakness  appear,  stimulants  and  heart-tonics  should  be 
resorted  to  ;  for  instance  : 

R  Powdered  digitalis-leaves,  0.1    (1 J  grains) ; 

Benzoic  acid,  0.3    [^      "      )  ; 

Camphor,  0.05  (  f  grain  ) ; 

Sugar,  0.5    (7|  grains).— M. 
Make  10  such  powders. 
Dose :  1  powder  every  three  hours. 

Under  such  conditions  strong  wine,  champagne,  or  cognac  may  also 
be  employed.  In  the  presence  of  pulmonary  edema  venesection 
may  be  recommended  in  addition  to  the  remedies  mentioned, 
while  but  little  success  can  be  hoped  for  from  bandaging  the 
extremities.  In  cases  of  fibrinous  ptneumonia,  in  drunkards  alcohol 
must  be  given  in  sufficient  amount  in  order  to  avoid  the  devel- 
opment of  delirium  tremens  and  cardiac  weakness.  Only  rarely 
is  the  fever  persistently  so  high  that  resort  must  be  had  to  anti- 
pyretics, among  which  phenacetin,  1.0  (15  grains),  is  to  be  pre- 
ferred. 


INTERSTITIAL  PNEUMONIA  (CIRRHOSIS  OF  THE 

LUNG). 

Ktiology. — Interstitial  pneumonia  may  occur  in  an  acute  or 
a  chronic  form.  Acute  inter stitial  pneumonia  is  attended  with  sup- 
puration in  the  interlobular  pulmonary  tissue,  so  that  the  indi- 
vidual infundibula  and  alveoli  are  separated  from  one  another  by 
collections  of  pus,  and  the  lung  in  the  inflamed  areas  resembles 
a   corrosion-preparation.     The  disorder   is,  therefore,  designated 


140  RESPIRATORY  ORGANS 

dissecting  pneumonia.  As  the  disease  is  not  recognizable,  during 
life,  it  is  without  clinical  significance.  Chronic  interstitial  pneu- 
monia is  usually  a  secondary  disorder,  generally  following  diseases 
of  the  bronchi,  the  lungs,  or  the  pleura.  It  develops  with  espe- 
cial frequency  in  the  sequence  of  chronic  bronchial  catarrJi,  whether 
this  exist  alone  or  have  given  rise  to  bronchial  dilatation.  Ca- 
tarrhal and  fibrinous  p)iciimoniu  also  at  times  give  rise  to  inter- 
stitial pneumonia,  the  former  especially  when  it  develops  in  the 
sequence  of  infectious  diseases  (whoo])ing-cough,  measles).  Ab- 
scesses, neic -growths,  echinococci,  and  tuberculous  processes  in  the 
lungs  also  frequently  give  rise  to  interstitial  pneumonia.  Very 
extensive  hyperplasia  of  the  pulmonary  interstitial  connective 
tissue  is  encountered  in  the  diseases  due  to  inhalation  of  dust, 
pneumonokonioses.  Pleurisy  is  often  the  cause  of  the  morbid 
alterations,  particularly  when  the  disease  has  pursued  an  insid- 
ious course,  and  has  given 'rise  to  dense  and  extensive  pleural 
adhesions.  It  is  still  a  matter  for  discussion  whether  jjrimari/ 
chronic  interstitial  pneumonia  occurs.  Among  the  causes  assigned 
for  such  a  condition  are  advanced  age,  alcoholism,  and  malarial 
influences. 

Anatomic  Alterations. — Interstitial  pneumonia  either  leads 
to  diffuse  connective-tissue  hyperplasia  or  gives  rise  to  the  for- 
mation of  dense  connective-tissue  nodules  in  the  lungs.  At 
times  both  varieties  of  alteration  are  associated.  The  connec- 
tive tissue  is  at  times  of  a  whitish,  at  other  times  of  a  grayish, 
or  of  a  blackish  or  a  slaty  color,  from  the  abundant  presence  of 
melanin.  Slate-colored  masses  of  connective  tissue  occur  at  the 
apices  of  the  lungs  with  especial  frequency,  where  they  often 
enclose  tuberculous  and  caseous  areas,  and  are  designated  slaty 
induration  or  slaty  cicatrization.  In  general,  interstitial  hyper- 
plasia of  the  connective  tissue  takes  place  frequently  for  the  pur- 
pose of  circumscribing  and  enclosing  foci  of  disease  in  the  lungs 
(abscess,  tuiuor,  parasites).  The  newly  formed  connective  tissue 
has  a  tendency  to  undergo  cicatricial  contraction,  and  it  thus 
frequently  haj^pcns  that  the  lung  is  irregularly  depressed  at  the 
seat  of  the  alterations.  If  the  hyperplasia  of  the  connective  tissue 
be  widespread,  the  lung  is  diminished  in  volume,  and  its  surface 
appears  more  or  less  extensively  fissured.  Such  a  condition  has 
been  designated  cirrliosis  of  the  lung. 

Microscopic  examination  shows  that  the  formation  of  connective  tissue 
may  originate  in  the  interstitial  connective  tissue  of  the  lungs  or  in  the  ter- 
minations of  the  bronchial  tubes  and  the  pulmonary  alveoli.  The  former 
occurs  in  connection  with  jileural  and  the  latter  in  connection  with  alveolar 
causes  (pneumonia). 

Sjrtnptoms  and  Diagnosis. — Airless  connective-tissue  areas 
in  the  lungs  can  be  diagnosed  during  life  only  when  they  have 
attained  an  extent  of  at  least  5  cm.  and  a  thickness  of  at  least 


INTERSTITIAL  PNEUMONIA  141 

2  cm.  They  then  manifest  themselves  especially  by  dulness, 
which  is  elicitable  over  small  areas  only  upon  light  percussion, 
and  by  retraction  of  the  borders  of  the  lungs  and  of  the  thorax. 
The  respiratory  murmur  over  such  areas  is  eitlier  enfeebled,  or 
over  areas  of  more  considerable  size  through  which  a  large  bron- 
chus passes  it  is  bronchial.  In  the  latter  event  vocal  fremitus  aild 
bronchophony  are  increased.  In  the  presence  of  daty  cicatrices  at 
the  apex  of  the  lung  it  is  important  to  note  differences  in  the  level 
of  the  apices,  a  most  valuable  means  of  recognizing  tuberculous 
alterations  existing  in  the  lung  situated  at  the  lower  level.  Uni- 
lateral contraction  of  the  lung  gives  rise  to  readily  recognizable 
alterations.  The  thorax  exhibits  unilateral  retraction,  participates 
but  little  in  the  i^espiratory  movements,  and  frequently  is  retarded 
temporarily  in  movement.  At  the  same  time  the  intercostal  spaces 
are  narrowed,  the  scapula  occupies  a  lower  level,  and  its  inner 
border  is  less  closely  applied  to  the  wall  of  the  chest,  and  the  verte- 
bral column  exhibits  scoliosis,  with  its  convevity  directed  to^vard 
the  healthy  side  of  the  chest.  On  pressure  upon  the  thorax  a  sense 
of  increased  resistance  is  conveyed  to  the  hand.  The  level  of  the 
apex  is  lower,  and  that  of  the  lower  margin  of  the  lung  is  higher 
than  normal.  Accordingly,  in  the  presence  of  contraction  of  the 
right  lung,  the  upper  border  of  the  lung  is  abnormally  high  (nor- 
mally at  the  upper  border  of  the  seventh  rib  in  the  right  mam- 
millary  line),  while  upon  the  left  side  the  semilunar  space  begins 
at  an  unusually  high  level  (normally  the  left  sixth  rib).  In  con- 
formity ^vith  the  excessive  elevation  of  the  diaphragm  the  apex  of 
the  heart  will  occupy  a  higher  intercostal  space  (normally  the  left 
fifth  intercostal  space)  in  the  presence  of  contraction  of  the  left 
lung,  and  when  the  margin  of  the  left  lung  is  retracted  considerably 
outward,  pulsatile  movements  of  the  exposed  pulmonary  artery 
become  apparent  in  tlie  left  second  intercostal  space.  Frequently 
not  only  a  cardiac-systolic  protrusion  is  observed  in  this  situation, 
but  also  a  cardiac-diastolic  vibration.  The  latter  is  dependent 
upon  increased  unfolding  of  the  semilunar  valves  of  the  pulmonary 
artery,  which  in  turn  is  dependent  upon  hypertrophy  of  the  right 
ventricle,  in  consequence  of  obliteration  of  pulmonary  capillaries. 
At  the  same  time  the  movements  of  the  heart  may  be  visible 
throughout  an  unusually  great  extent.  At  times  the  heart  under- 
goes great  displacement,  and,  in  the  event  of  contraction  of  the 
right  lung,  it  is  drawn  far  into  the  right  half  of  the  chest  and  with 
contraction  of  the  left  lung  out  to  the  left  axillary  line.  The  healthy 
lung  frequently  undergoes  compensatory  emphysema,  which  is 
indicated  upon  the  right  by  depression  of  the  lower  margin  of  the 
lung,  and  upon  the  left  side  by  diminution  in  the  area  of  cardiac 
dulness  and  of  the  semilunar  space.  The  respiratory  disturbances 
may  be  thus  so  completely  neutralized  that  the  patients  are  scarcely 
conscious  of  any  distress.     The  principal  dangers  of  the  disease 


142  RESPIRATORY  ORGANS 

reside  either  in  the  causative  disorder  or  in  paralysis  of  the  right 
side  of  tlie  lieart  and  in  eonditi(jns  of  stasis. 

Prognosis. — Altiiough  the  prognosis  of  interstitial  pneumonia 
is  unt'av(»ral)k'  in  so  far  as  tlie  disorder  is  incurable,  it  must  not  be 
overloolvcd  tliat  some  cases  re})resent  natural  curative  processes  or 
tend  to  restrict  the  progress  of  destructive  alterations  in  the  lungs. 

Treatment. — Internal  remedies  afford  no  relief.  Respiratory 
gymnastics  should  be  prescribed,  the  arm  upon  the  diseased  side 
being  raised  upon  a  high  object  (as  a  door  or  a  chest),  and  deep 
inspirations  l)eing  made  several  times  daily  in  order  to  fill  the  con- 
tracted lung  more  thoroughly  with  air,  or  the  healthy  lung  is  for  a 
time  restricted  in  its  movement  by  the  application  of  a  bandage  in 
order  to  stimulate  the  diseased  lung  to  greater  activity. 

SUPPURATION  OF  THE  LUNG  (PULMONARY 
ABSCESS). 

Htiology. — Suppuration  in  the  lungs  scarcely  occurs  apart 
from  the  entrance  of  pyogenic  cocci,  among  which  the  Streptococcus 
pyogenes  and  the  Staphylococcus  pyogenes  aureus  especially  have 
been  demonstrated.  In  isolated  instances  the  pneumoniacocci  of 
Frankel,  the  Bacterium  coli  commune,  and,  in  my  clinic,  influenza- 
bacilli  have  also  been  observed  as  the  exciting  agents  of  suppura- 
tion. The  pyogenic  organisms  may  gain  entrance  into  the  lungs 
through  the  bronchi  and  alveoli  (bronchogenic  and  pulmogenic), 
through  the  blood-vessels  (hematogenous),  or,  by  perft)ration,  from 
adjacent  organs.  Aspirated  foreign  bodies  constitute  a  not  un- 
common cause  for  suppuration  in  the  lungs,  and  especially  aspirated 
particles  of  food.  For  this  reason  the  disorder  is  frequently  ob- 
served in  those  who  are  seriously  ill  (typhoid  fever),  in  the  debili- 
tated, and  in  persons  with  difficulty  in  deglutition,  whether  this  be 
dependent  upon  paralysis  of  the  pharyngeal  structures,  of  the 
larynx,  of  the  esophagus,  or  upon  constriction  of  the  last.  Patients 
suffering  from  excessive  and  frequent  vomiting  are  also  exposed 
to  the  danger  of  aspirating  material  into  the  lungs  and  thus  to 
pulmonary  suppuration.  At  times  suppuration  in  the  lungs  suc- 
ceeds upon  preexisting  catarrhal,  but  especially  fibrinous,  pneumonia. 
The  danger  is  not  inconsiderable,  especially  when  the  inflamma- 
tion is  extensive,  and  the  powers  of  resistance  of  the  patient 
(drunkard)  are  diminished.  Hematogenous  sup])urati<>n  of  the 
lung  occurs  at  times  in  the  sequence  of  suppuration,  ulceration,  and 
inflammation,  in  the  distribution  of  the  inferior  vena  cava,  thus  in 
conjunction  with  jmerperal  ])rocesses,  interstitial  ulceration,  etc. 
Ulcerative  endocarditis  involving  the  right  side  of  the  heart  also 
affords  opportunity  for  the  development  of  embolic  pulmonary 
abscesses.  At  times  suppuration  in  the  lungs  is  excited  by  rupture 
of  suppurative  processes  in  adjacent  organs,  as,  for  instance,  pleural 


SUPPURATION  OF  THE  LUNG  143 

empyema,  pyopericardium,  abscess  of  the  liver  and  of  the  spleen, 
and  burrowing  abscess  of  the  vertebral  column.  Suppuration  of 
the  lung  is  not  a  common  disorder,  and  is  only  exceptionally 
observed  in  childhood. 

Anatomic  Alterations. — In  accordance  with  the  number 
of  foci  present  a  distinction  must  be  made  between  single  and  mul- 
tiple abscess  of  the  lung.  Multiple  abscesses  of  the  lung  occur 
especially  as  a  result  of  hematogenous  influences  and  of  the  aspi- 
ration of  food.  Pulmonary  abscesses  vary  greatly  in  size.  At 
times  they  are  barely  visible  (^miliary  abscess  of  the  lung),  while  in 
other  instances  they  involve  the  largest  part  of  a  pulmonary  lobe. 
Accordingly  as  the  pus  lies  free  in  the  pulmonary  tissue,  or  is  sur- 
rounded by  a  membrane  resulting  from  interstitial  pneumonia,  the 
condition  is  designated  a.  free  or  an  encapsulated  pulmonary  abscess. 
The  former  is  distinguished  by  an  irregular  villous  wall,  the  latter 
by  a  smooth  wall.  It  may  further  happen  that  the  encapsulation 
is  incomplete.  The  a,mount  of  pus  varies,  and  in  addition  to  the 
size  of  the  purulent  focus,  it  depends  especially  upon  the  fact 
whether  copious  expectoration  has  taken  place  shortly  before 
death. 

Symptoms  and  Diagnosis. — The  most  important  phenom- 
enon for  the  recognition  of  an  abscess  of  the  lung  is  the  peculiar 
expectoration.  This  is  purulent,  diffluent,  and  abundant,  so  that  it 
may  be  as  much  as  500  c.c.  in  the  course  of  a  day.  It  usually 
gives  off  an  acid,  buttermilk-like  odor.  Of  especial  significance 
is  the  occurrence  of  shreds  of  pulmonary  tissue,  which  on  micro- 
scopic examination  exhibit  a  gray  or  a  blackish  color,  as  well  as 
the  alveolar  structure  of  the  pulmonary  tissue.  They  may  attain 
the  size  of  a  phalanx  of  the  thumb. 

At  times  hematoidin-crystals  are  found  in  the  sputum,  and  if  the  disease 
pursue  a  chronic  course  cholesterin-plates  also  may  be  present. 

Frequently,  expectoration  in  niouthfuls  is  noteworthy.  The 
patients  expectorate  but  seldom,  although  on  each  occasion  such 
large  amounts  of  pus  are  expelled  as  to  be  frequently  discharged 
from  the  mouth  and  the  nose,  and,  if  they  in  part  reenter  the 
esophagus  and  the  larynx,  to  give  rise  to  vomiting  and  renewed 
cough.  Of  importance  also  is  the  attitude  of  the  patient,  who 
usually  lies  constantly  upon  the  affected  side,  in  order  that  the 
secretion  may  collect  for  a  long  time  before  it  reaches  the  mouth 
of  the  entering  bronchus  and  excites  cough ;  in  the  presence  of 
centrally  situated  purulent  foci  in  the  lungs  the  expectoration  may 
be  the  only  means  by  which  it  is  possible  to  recognize  the  affec- 
tion, while  from  the  attitude  of  the  patient  the  lung  in  which  the 
lesion  is  situated  may  be  suspected.  The  local  conditions  found 
in  the  lung  vary  accordingly  as  the  abscess-cavity  is  filled  with 
pus  or  contains  air,  between  manifestations  of  airlessness  and  those 


144  RESPIRATORY  ORGANS 

of  ciivity-formation.  The  course  of  suppuration  of  the  lung  is  usu- 
ally acute.  Generally  there  is  fever,  which  often  exhibits  a  hectic 
character.  The  patients  attract  attention  on  account  of  pallor,  a 
tendency  to  sweating,  anorexia,  in  short,  on  account  of  septic  mani- 
festations. Death  may  result  from  increasing  asthenia,  or  from 
complications,  such  as  gangrene  of  the  lung  and  pyopneumothorax. 
At  times  a  focus  of  suppuration  in  the  lung  ruptures  externally, 
and  gives  rise  to  extensive  burrowing  beneath  the  skin.  Complete 
recovery  may,  however,  take  place,  leaving  only  circumscribed 
retraction  of  the  chest  and  dulness  on  percussion. 

Prognosis. — Although  the  prognosis  of  suppuration  of  the 
lung  is  always  serious,  recovery  not  rarely  occurs. 

Treatment. — Tn  the  first  place,  an  effort  should  be  made  to 
sustain  the  bodily  strength  by  means  of  a  nutritious  diet.  In 
addition  balsamics  and  disinfectants  should  be  employed  to  prevent 
sujjpuration  and  decomposition  of  the  pus ;  for  instance  : 


R  Oil  of  turpentine,  10.0  (2^  fluidrams). 

Dose:  10  drops  in  milk  thrice  daily. 


Oi 


R   Creosote,  0.15  (2i  minims). 

Make  100  such  gelatin-capsules. 

Dose :  1  capsule  every  two  or  three  hours. 

Abscesses  of  the  lungs  have  in  a  niuuber  of  instances  been  sub- 
jected to  operative  intervention,  Mhich  has  resulted  in  recovery  in 
about  60  per  cent,  of  the  cases. 

GANGRENE  OF  THE  LUNG. 

Ktiology. — Gangrene  of  the  lung  is  characterized  by  the 
occurrence  first  of  moiiification  and  then  of  putrid  decomposition 
of  the  necrotic  pulmonary  tissue.  The  first  alteration  results  from 
an  enormous  invasion  by  pyogenic  cocci,  especially  the  various 
forms  of  Staphylococcus  pyogenes,  while  the  putrefaction  is  induced 
by  the  putrefactive  bacteria  (Leptothrix  pulmoiialis,  oidium,  Bacte- 
rium coli  commune,  etc.).  Pulmonary  gangrene  is  not  a  common 
disorder,  and  experience  has  shown  that  it  occurs  most  frequently 
in  men  between  the  sixteenth  and  the  fortieth  year  of  life.  It 
may  be  of  bronchogenic,  alveolar,  or  hematogenous  origin.  At  times 
putrid  bronchitis  extends  to  the  pulmonary  tissue,  and  gives  rise 
to  gangrene  of  the  lung.  Aspirated  foreir/n  bodies  and  particles  of 
food  also  not  rarely  cause  pulmonary  gangrene.  Sometimes  this 
condition  has  been  observed  in  the  sequence  of  carcinoma  of  the  lips 
and  of  the  tongue,  and  of  operations  upon  the  oropharyngeal  cavity, 
when  ]>utrid  masses  of  degenerated  a)id  disintegrcded  material  have 
gained  entrance  into  the  larynx,  and  thence  more  deeply  into  the 
bronchial  tubes  and  alveoli,  and  have  excited  inflammation  and 


GANGRENE  OF  THE  LUNG  145 

putrefaction  in  the  lungs.  At  times  the  exciting  agents  of  disease 
gain  entrance  only  after  preceding  rupture  into  the  bronchial  tubes, 
as,  for  instance,  in  the  sequence  of  carcinoma  of  the  esophagus, 
burrowing  abscesses  attending  tuberculosis  of  the  vertebrse,  sup- 
puration of  the  bronchial  glands,  new-growths  and  suppuration  in 
the  mediastinum,  carcinoma  of  the  stomach,  gastric  ulcer,  etc. 
Among  the  alveolar  causes  fibrinous  and  less  commonly  catarrhal 
pneumonia  should  be  mentioned  first.  Drunkards  and  debilitated 
persons  are  especially  exposed  to  the  danger  that  pneumonia  may 
be  transformed  into  gangrene  of  the  lung.  Abscess  of  the  lungy 
pulmonary  tuberculosis,  carcinoma  of  the  lunr/,  and  echinococcus  of 
the  lung,  may  also  give  rise  to  gangrene  of  the  lung.  Occasionally 
pulmonary  gangrene  occurs  in  the  sequence  of  injuries  to  the  lung. 
Among  such  factors  are  not  alone  gunshot  wounds,  stab-wounds, 
and  punctured  wounds,  but  also  blunt  injuries,  such  as  contusions 
of  the  thorax,  and  a  long  time  may  elapse  before  the  gangrene 
supervenes  upon  the  injury.  Hematogenous  gangrene  of  the  lung 
may  be  due  to  pulmonary  embolism.  This  occurs  especially  when 
emboli  are  derived  from  putrid  foci,  as,  for  instance,  in  cases  of 
septicemia,  caries  of  the  mastoid  process,  abscess  of  the  liver  or 
of  the  brain,  gangrene  and  diphtheria  of  the  skin.  Certain  con- 
tributory causes  may  favor  the  occurrence  of  gangrene  of  the  lung. 
Among  these  may  be  mentioned  alcoholism,  asthenia,  over-crowd- 
ing, and  deficient  ventilation  of  living-rooms.  Pulmonary  gangrene 
has  occasionally  been  observed  to  occur  endemically  under  such  con- 
ditions. Gangrene  of  the  1  ung  occurs  not  rarely  in  cases  of  diabetes. 
Anatomic  Alterations. — It  is  customary  to  make  a  distinc- 
tion between  circumscribed  and  diffuse  gangrene  of  the  lung,  accord- 
ingly as  the  gangrenous  area  is  sharply  demarcated  from  the 
healthy  pulmonary  tissue,  or  gradually  passes  into  healthy  tissue 
without  sharp  limitation.  The  diseased  pulmonary  tissue  at  first 
appears  as  a  friable,  brownish,  and  putrid  or  offensive-smelling 
mass,  which  suggests  the  appearance  of  an  erosion  effected  with 
potassium  hydroxid.  The  tissue  gradually  undergoes  softening, 
and  its  products  usually  find  exit  externally  through  a  bronchus. 
If  expectorated,  it  is  replaced  by  a  gangrenous  pulmonary  cavity, 
which  at  first  exhibits  a  ragged  and  villous  inner  surface.  This 
cavity  may  be  gradually  encapsulated  by  connective  tissue,  which 
forms  in  consequence  of  interstitial  pneumonia,  and  the  formation 
of  granulations  upon  the  inner  surface  may  eventually  lead  to  oblit- 
eration of  the  cavity.  The  number  and  the  size  of  the  gangrenous 
areas  in  the  lungs  are  subject  to  wide  variation.  At  times  a  single 
area  may  occupy  an  entire  lobe,  or  even  an  entire  lung.  Usually 
the  gangrenous  foci  are  situated  at  the  surface  of  the  lung,  and  this 
is  especially  true  of  embolic  foci.  The  bronchi  generally  exhibit 
signs  of  inflammation,  and  their  mucous  membrane  may  also  suffer 
loss  of  structure. 

10 


146  RESPIRATORY  ORGANS 

Symptoms,  Diagnosis,  and  Prognosis. — In  the  recoirni- 
tion  of  gaugrcne  of  the  hmg  the  churaeter  of  the  expectoration 
is  decisive.  In  the  first  place,  the  sputum  often  diffuses  an  un- 
bearablij  offensive  odor,  which  is  penetrating  and  has  been  com- 
pared with  that  of  horse-radish.  Often  the  air  of  the  room  is 
contaminated  within  the  shortest  period  of  time  by  the  fetid  odor. 
In  some  cases  the  expectoration  loses  its  offensive  odor  when 
exposed  to  the  air,  but  this  becomes  again  unmistakably  apparent 
as  soon  as  the  sputum  is  vigorously  agitated  in  a  vessel.  The 
amount  of  expectoration  not  rarely  reaches  500  c.c.  and  more  per 
day,  and  its  consistency  is  diffluent.  In  accordance  with  its  prin- 
■cipal  constituents  the  sputum  is  mucopurulent,  the  purulent  masses 
forming  grayish-green  opaque  globules.  The  tendency  of  the  ex- 
pectoration to  form  layers  is  noteworthy.  On  standing  for  some 
time  four  layers  can  be  distinguished  in  the  sputum.  The  upper- 
most is  a  frothy  layer ;  the  next,  one  of  purulent  masses ;  then 
follows  a  grayish-green,  thin  serous  layer ;  and  the  lowermost  is 
a  crumbling  layer  of  sediment.  The  expectoration  may  acquire 
a  reddish-yellow  or  clay-colored  appearance,  in  consequence  of  the 
presence  of  disintegrated  hemoglobin. 

In  contradistinction  from  putrid  bronchitis  the  presence  of 
shreds  of  pulmonary  tissue  in  the  expectoration  is  decisive  in 
diagnosis,  and  these  may  usually  be  readily  recognized  from  their 
smoky-gray  color.  They  may  be  larger  than  the  extremity  of  the 
thumb,  and  consist  merely  of  exfoliated  pulmonary  tissue.  Their 
number  varies  widely.  On  microscopic  examination  the  alveolar 
structure  of  the  lungs  can  be  detected.  The  contained  elastic 
fibers  have  not  rarely  undergone  destruction,  probably  in  conse- 
quence of  a  digestive  process,  as  ferments  resembling  trypsin  have 
been  obtained  from  the  sputum. 

Frequently  yellowish  or  even  brownish  particles,  so-called 
Dittrich  or  mycotic  bronchial  plugs,  are  found  in  the  sediment-layer 
of  the  sputum,  and  which,  as  has  been  disclosed  on  post-mortem 
examination,  form  in  the  bronchial  tubes  that  enter  the  gangrenous 
area.  If  these  plugs  are  compressed,  they  diffuse  a  peculiarly  dis- 
agreeable odor.  On  microscopic  examination  they  are  found  to 
consist  mainly  of  bacteria,  partly  bacilli,  and  partly  cocci.  On 
addition  of  tincture  of  iodin  the  l^acteria  largely  acquire  a  violet 
or  bluish  color,  like  the  leptothrix-fi laments  in  the  mouth,  whence 
the  name  Leptothrix  pulmonalis.  Further,  only  the  interior  of  the 
leptothrix  is  stained  violet  or  bluish,  while  the  peripheral  mem- 
brane appears  bright  yellow.  At  times  thicker  structures  are 
found,  with  eel-like  movement,  and  also  spirilla.  Infusoria  have 
also  been  observed,  monas  lens  and  cercomonas.  The  former 
appears  as  a  roundish  glolnde  with  an  oscillating  flagellum,  while 
the  latter  is  of  oblong  shape  with  a  tail-like  process  posteriorly, 
and  one  or  two  fla^ella  anteriorlv.     In  addition  to  bacteria  and 


GANGRENE  OF  THE  LUNG  147 

infusoria,  needles  of  fatty  acids,  fat-globules,  flakes  of  pigment, 
and  hematoidin-crystals  are  also  found  in  the  bronchial  plugs. 

At  times  expectoration  is  wanting  in  cases  of  pulmonary  gan- 
grene, and  only  the  offensive  odor  of  the  expired  air  is  noted.  The 
condition  is  to  be  distinguished  from  simple  fetor  of  the  breath 
originating  in  the  mouth  from  the  fact  that  the  latter  is  not 
appreciable  at  a  short  distance  from  the  patient,  while  the  putrid 
odor  of  the  expired  air  persists.  Not  rarely  patients  have  them- 
selves first  noticed  this  odor,  which  may  create  an  aversion  to  food 
and  drink.  I  have  seen  patients  die  of  pulmonary  gangrene  who 
presented  no  other  morbid  manifestation  than  the  horribly  offensive 
odor  of  the  expired  air. 

Individuals  with  pulmonary  gangrene  unconsciously  prefer  the 
lateral  decubitus  upon  the  affected  side  of  the  body,  in  order  that 
the  fluid  secretion  may  collect  in  the  gangrenous  cavity  for  as  long 
a  time  as  possible  before  reaching  the  mucous  membrane  of  the 
afferent  bronchus,  and  thus  induce  cough.  When  the  gangrenous 
area  is  situated  centrally  the  aifected  side  may  be  recognized  from 
the  attitude  of  the  patient.  The  condition  just  described  explains 
why  the  patients  expectorate  but  seldom,  though  in  great  amounts 
— so-called  expectoration  in  mouthfuh. 

The  local  pulmonary  alterations  consist  either  in  signs  of  infil- 
tration (dulness  on  percussion,  bronchial  breathing,  ringing  rales, 
increased  vocal  fremitus  and  bronchophony)  or  in  signs  of  a  cavity 
(dull-tympanitic  and  even  metallic  percussion-note,  bronchial  or 
metallic-bronchial  breathing,  metallic-ringing  rales,  increased  vocal 
fremitus  and  bronchophony,  variation  in  the  percussion-note  be- 
tween dull  and  tympanitic  accordingly  as  the  gangrenous  cavity 
contains  secretion  or  after  previous  expectoration  air). 

Patients  with  pulmonary  gangrene  usually  attract  attention 
by  reason  of  their  ashen-gray  complexion,  and  they  rapidly  lose 
strength.  Generally  the  temperature  is  elevated,  and  the  fever 
may  be  of  hectic  type.  The  appetite  is,  as  a  rule,  impaired,  and 
diarrhea  readily  occurs  in  those  who  swallow  their  expectoration, 
in  consequence  of  decomposition  of  the  ingested  food. 

The  course  of  the  disease  may  be  acute,  subacute,  or  chronic. 
At  times  death  takes  place  from  progressive  asthenia  within  a  few 
days.  Nevertheless,  the  disease  may  terminate  in  recovery,  and 
the  signs  of  a  cavity  may  recede  in  consequence  of  cicatrization, 
which  is  indicated  by  retraction  of  the  chest  and  dulness  on  per- 
cussion. Not  rarely  improvement  and  aggravation  of  the  disorder 
frequently  alternate  with  each  other. 

Complications  are  common.  Among  these  one  of  the  most 
serious  is  pulmonary  hemorrhage.  The  danger  of  this  accident 
resides  especially  in  the  fact  that  the  blood  (perhaps  in  conse- 
quence of  the  presence  of  ferments  in  the  sputum)  undergoes 
coagulation  with  difficulty,  so  that  death  may  result  from  hemor- 


148  RESPIRATORY  ORGANS 

rhage.  At  times  j)leurisy  is  superadded  to  gangrene  of  the  lung. 
The  fluid  exudate  may  be  serous,  puruk'ut,  or  putrid,  and  in  the 
presence  of  putrid  pk'ural  effusions  that  apparently  occur  without 
appreciable  cause  suspicion  should  always  be  aroused  that  they 
may  liave  been  excited  by  a  concealed  focus  of  gangrene  in  the 
lung.  Rupture  of  the  pulmonary  pleura  will  be  followed  by 
pneumotJwra.r,  usually  by  liydropneumothorax.  Strangely,  the 
exudate  under  the  conditions  last  named  may  be  serous.  At  times 
rupture  of  the  gangrenous  process  may  take  place  externally,  and 
long  fistulous  passages  may  form.  Rupture  into  the  mediastinum, 
into  the  pericardial  cavity,  into  the  esophagus,  and  through  the 
diaphragm,  has  also  been  observed.  In  some  cases  metastases  in 
distant  organs  take  place  through  dissemination  of  pyogenic  micro- 
organisms ;  for  instance,  abscess  of  the  brain  or  of  the  liver.  I 
have  also  observed  multiple  painful  swelling  of  the  joints. 

Among  the  secondary  condit'ions  observed  is  the  formation  of  drmnstick- 
finrfers,  when  pulmonary  gangrene  pursues  a  chronic  course. 

Treatment. — ^^'ith  reference  to  prophylactic  measures,  atten- 
tion may  be  directed  especially  to  the  importance  of  carefully 
feeding  by  means  of  the  stomach-tube  persons  suffering  from  diffi- 
culty in  deglutition.  The  treatment  of  pulmonary  gangrene  is 
based  upon  similar  lines  to  those  that  govern  that  of  suppuration 
of  the  lungs.  A  nutritious  diet  is  prescribed,  and  the  use  of  alcohol 
should  be  permitted  for  the  purpose  of  sterilizing  sputum  that  may 
have  lieen  swallowed.  If  possible  the  patient  should  be  placed  in 
a  spacious  room,  which  he  should  occupy  alone,  because  contamina- 
tion of  the  air  is  injurious  and  the  offensive  odor  of  the  expectora- 
tion and  of  the  exjjired  air  would  be  extremely  disagreeable  to 
other  occupants.  The  offensive  odor  of  the  expectoration  can  to 
a  certain  extent  be  neutralized  by  the  introduction  of  J  .0  or  2.0 
(15  to  30  grains;)  of  naphthalin  into  the  sputiun-cup,  and  covering 
this  with  a  tightly  closing  lid.  The  room  must  be  frequently  and 
thoroughly  ventilated.  On  fine  days  the  patient  should  be  exposed 
to  the  open  air.  Among  internal  remedies  balsamics  and  disin- 
fectants may  be  recommended  to  restrict  the  secretion  and  decom- 
position ;  for  instance  : 

R     Oil  of  turpentine,  10.0  (21  ffuidrams). 

Dose:  10  drops  thrice  daily  in  milk. 


Or, 


Or, 


R     Myrtol  0.15  (2J  minims). 

]\Iake  30  such  gelatin-cajisules. 
Dose :  1  or  2  capsules  every  two  or  three  hours. 


R     Creosote,  0.15  {2h  minims), 

^lake  30  such  gelatin-capsules. 
Dose:  1  capsule  every  two  or  three  hours. 

It  is  advisable  to  place  in  the  room  three  or  four  times  daily 
vessels  containing  hot  water  to  which  10  drops  of  oil  of  turpentine 


NEW-GROWTHS  OF  THE  LUNG  149 

or  of  creosote  have  been  added,  or  in  winter  upon  the  stove  or  in 
the  stovepipe,  in  order  that  the  patient  may  inhale  the  vapor.  The 
employment  of  inhalation-apparatus  and  inhalation-masks  is  less 
convenient  to  the  patient,  and  in  my  experience  does  not  yield 
better  results.  Operative  treatment  of  pulmonary  gangrene  has 
also  been  attempted  (incision  and  drainage  or  thermocautery),  and 
recovery  has  followed  in  about  50  per  cent,  of  the  cases. 

NEW-GROWTHS  OF  THE  LUNG. 

Ktiologfy. — Among  tumors  of  the  lungs  only  carcinomata  and 
sarcomata  are  of  clinical  significance.  Both  varieties  of  new- 
growth  usually  develop  secondarily.  The  organ  primarily  involved 
is  at  times  remote  from  the  lungs,  at  times  in  close  proximity,  so 
that  under  the  latter  conditions  the  new-growth  extends  directly 
into  the  lung,  as,  for  instance,  from  carcinoma  of  the  esophagus, 
the  vertebral  column,  or  the  mammary  gland.  Primary  carcinoma 
and  sarcoma  of  the  lungs  are  exceedingly  uncommon.  At  times 
traumatism  is  assigned  as  the  cause.  Primary  carcinoma  of  the 
lung  has  been  observed  frequently  in  miners  in  the  cobalt-mines 
of  Schneeberg,  and  has  been  attributed  to  the  inhalation  of  dust 
containing  arsenic.  Both  carcinomata  and  sarcomata  of  the  lunges 
occur  more  commonly  in  men  than  in  women,  and  they  develop 
principally  after  the  fortieth  year  of  life.  Sarcomata  are  considerably 
less  common  than  carcinomata. 

Anatomic  Alterations. —  Carcinoma  of  the  lung  appears  in 
two  forms,  either  as  an  infiltrating  growth,  whose  limits  are  not 
sharply  circumscribed  with  relation  to  the  healthy  tissue,  or  as  a 
nodular  growth.  The  nodules  vary  in  size.  At  times  the  lung  is 
filled  with  innumerable  small  carcinomatous  nodules,  which  sug- 
gest the  appearance  of  miliary  tubercles,  whence  also  the  designa- 
tion miliary  carcinosis  of  the  lung ;  while  in  other  instances  a 
single  carcinomatous  nodule  occupies  almost  an  entire  pulmonary 
lobe.  jSTot  rarely  the  nodules  project  from  the  surface  of  the  lung 
as  hemispherical  tumors,  whose  centers  exhibit  a  slight  depression 
(carcinomatous  umbilication).  The  number  of  carcinomatous 
nodules  is,  like  their  size,  also  susceptible  of  wide  variation.  All 
varieties  of  carcinoma  have  been  observed  in  the  lungs — the  hard 
scirrhus,  the  juicy  and  soft  medullary  carcinoma,  the  alveolar  car- 
cinoma, and  the  epithelial  carcinoma.  Primary  carcinoma  of  the 
luug  arises  at  times  from  the  epithelium  of  the  bronchial  mucous 
membrane  or  of  the  bronchial  glands,  at  other  times  from  the 
alveolar  epithelium.  In  cases  of  secondary  carcinoma  of  the  lung 
the  elements  of  the  disease  gain  entrance  into  the  lungs  partly 
through  the  lymphatics  and  partly  through  the  blood-vessels.  The 
neoplasm  extends  by  preference  from  the  hilus  into  the  lungs, 
where  it  follows  the  ramifications  of  the  bronchial  tubes,  advancing 


150  RESPIRATORY  ORGANS 

especially  within  the  lymphatics  of  the  peribronchial  connective 
tissue.  Experience  has  shown  that  primary  carcinoma  of  the.  lung 
involves  most  commonly  the  right  upper  lobe,  while  pulmonary 
sarcoma  is  more  common  in  the  left  Iniig. 

Symptoms,  Diagnosis,  and  Prognosis. — The  most  cer- 
tain symptom  of  carcinoma  and  sarcoma  of  tlie  lung  is  the  appear- 
ance of  tumor-particles  in  the  expectoration,  although  this  occurs 
but  seldom.  At  times  such  particles  are  demonstrable  only  micro- 
scopically, although  in  one  case  of  sarcoma  of  the  lung  I  have 
found  in  the  expectoration  pieces  of  new-growth  as  large  as  the 
end  of  the  thumb.  As  may  be  understood,  the  expectoration  of 
particles  of  new-growth  can  only  take  place  if  the  tumor  has  pre- 
viously undergone  softening,  and  the  softened  masses  have  ruptured 
into  a  bronchus.  Not  rarely  hemorrhage  takes  place  into  sarco- 
mata and  carcinomata  of  the  lungs.  There  may  thus  at  times  be 
repeated  hemoptysis,  which  becomes  serious  by  reason  of  its  pro- 
fuseness  ;  or  if  the  blood  is  retained  for  some  time  in  the  air-passages, 
in  consequence  of  transformation  of  the  hemoglobin,  a  raspberry- 
jelly-like  or  currant-jelly-like,  reddish  or  brownish-black,  or  even  a 
greenish  material,  is  expectorated,  which  is,  to  a  certain  degree, 
distinctive  of  the  aifection,  though  it  is  also  observed  at  times  in 
cases  of  pulmonary  tuberculosis.  The  local  phenomena  referable  to 
the  chest  are  variable.  In  the  first  place,  neoplasms  of  the  lung 
may  conceal  themselves  behind  a  plcnrisij.  Under  such  conditions 
bloody,  fat-containing,  and  colloid  exudates  especially  are  suspi- 
cious. On  microscopic  examination  of  the  fluid  obtained  by 
puncture,  the  presence  of  fatty  granule-cells  and  of  cells  with 
numerous  nuclei  should  be  looked  for.  Miliary  carcinosis  of  the 
lungs  at  times  strongly  suggests  the  clinical  picture  of  miliary 
tuberculosis  of  the  lungs.  The  patients  attract  attention  espe- 
cially on  account  of  extreme  dyspnea  and  cyanosis,  and  death 
results  from  suifocation.  Tumors  of  considerable  size  may  be 
recognized  from  the  presence  of  percussion-dulness  of  irregular 
outline.  If  the  entire  lung  is  involved  in  the  new-formation,  flat- 
ness is  obtained  everywhere  upon  the  affected  side  of  the  chest, 
and  generally  increased  resistance  also  is  appreciable.  If  the 
bronchi  are  not  occluded  by  carcinomatous  masses,  bronchial 
brecdhing  will  be  audible.  Under  such  conditions  vocal  fremitus 
and  resonance  ai'c  increased.  The  chest  is  frequently  enlarged. 
Adjacent  organs  (heart,  liver)  are  displaced.  By  compression  or  by 
extension  of  the  \\e\\-irYO\\\\\  prexsure-manifestations  are  not  rarely 
induced  in  adjacent  organs,  among  which  may  be  mentioned  brachial 
and  intercostal  neuralgia,  constriction  of  the  esophagus,  tracheal 
and  bronchial  stenosis,  pressure  upon  the  veins  of  the  neck  with 
resulting  cyanosis  and  tumefaction  of  the  skin,  and  paralysis  of  the 
vocal  bands.  At  times  the  supraclavicular -^nd  the  axillary  lymph- 
glands  are  enlarged  and  degenerated.     The  patients  suffer  mostly 


ECHINOCOCCUS  OF  THE  LUNG  151 

from  dyspnea,  and  alarming  attacks  of  threatening  suffocation  often 
occur.  The  disease  terminates  almost  unexceptionally  in  the  course 
of  a  few  months  in  death,  which  results  in  consequence  of  pro- 
gressive dyspnea  or  of  marasmus,  less  commonly  from  uncon- 
trollable hemorrhage.  At  times  pulmonary  gangrene  has  been 
superadded  to  carcinoma  of  the  lung.  In  rare  cases  rupture  ex- 
ternally has  also  been  observed. 

Treatment. — Treatment  can  be  directed  only  to  the  amelio- 
ration of  distressing  symptoms.  Subcutaneous  injection  of  mor- 
phin  especially  will  frequently  be  required.  Kronlein  in  one  case 
removed  successfully  a  sarcoma  of  the  lung  by  operative  means. 

ECHINOCOCCUS  OF  THE  LUNG. 

Echinococcus  of  the  lung  is  a  rare  disease  that  is  acquired  by 
aspiration  of  the  ova  of  the  Taenia  echinococcus  of  the  dog.  The 
echinococcus-cyst  may  have  developed  priinarily  in  the  lung,  or 
have  invaded  the  lung  secondarily  from  other  organs,  as,  for  in- 
stance, in  the  presence  of  echinococcus  of  the  heart,  by  embolism, 
or  of  echinococcus  of  the  liver  following  rupture  through  the  dia- 
phragm. The  echinococcus-cyst  is  almost  always  monolocular. 
The  condition  consists  in  the  development  of  a  vesicle  with  milk- 
glass-like  walls,  containing  clear  fluid,  and  frequently  also  daugh- 
ter-cysts. At  times  suppuration  occurs  in  an  echinococcus-cyst, 
and  in  consequence  of  inspissation  a  putty-like  mass  forms.  Most 
frequently  echinococcus-cysts  have  developed  in  the  right  lower 
lobe.  In  size  they  may  become  as  large  as  a  man's  head.  Multi- 
locidar  echinococcus  of  the  lung  has  been  observed  in  only  a  few 
iustances.  The  individual  vesicles  were  developed  either  in  the 
distribution  of  the  pulmonary  artery,  or  in  that  of  the  pulmonary 
veins. 

Echinococci  of  the  lungs  can  scarcely  be  diagnosed  with  cer- 
tainty unless  echinococcus-cysts  or  echinococcus-hooklets  are  found 
in  the  sputum.  The  membranes  may  be  readily  recognized  from 
their  laminated  structure,  and  no  difficulty  is  encountered  in  recog- 
nizing echinococcus-hooklets.  When  echinococcus-membranes  are 
expectorated  they  may  be  replaced  by  gangrene  of  the  lung. 

At  times  echinococcus  of  the  lung  is  attended  with  frequent 
hemoptysis,  concerning  whose  origin  doubt  still  exists.  When 
echinococcus-cysts  are  seated  at  the  surface  of  the  lung  their 
presence  is  disclosed  by  duhiess  on  percussion  of  irregular  outline 
and  over  which  the  respiratory  murmur,  vocal  fremitus,  and 
bronchophony  are  wanting.  Frequently  the  patients  complain 
of  dyspnea  and  of  stabbing  pain  in  the  side.  Echinococcus-cysts 
have  a  tendency  to  grow  and  to  rupture  into  adjacent  cavities. 
Rupture  into  the  bronchial  tubes  has  already  been  mentioned. 
Ru])ture  may  take  place  also  into  the  pleural  cavity,  to  which 


152  RESPIRATORY  ORGANS 

pleurisy,  pneumothorax,  or  hydropneuniothorax  will  b.e  super- 
added.    Rnj)turc  may  even  take  place  througli  the  chest- wall. 

The  prognosis  of  cchinococeus  of  the  lung  is  serious.  Among 
otlier  conditions  sudden  rupture  or  exploratory  puncture  may  be 
followed  by  the  entrance  of  echinococcus-fluid  into  the  air-pass- 
ages, and  death  from  suffocation. 

The  treatment  can  only  be  surgical,  the  cyst  being  removed 
by  means  of  the  knife  or  the  thermocautery. 

ANEURYSM  OF  THE  PULMONARY  ARTERY. 

Aneurysm  of  the  pulmonary  artery  is  rare,  but  it  may  occur 
even  in  early  life.  It  gives  rise  to  a  diffuse  (expansile)  pulsating 
tumor  in  the  left  second  intercostal  space,  to  cardiac-systolic 
murmurs,  and  to  dilatation  and  hypertrophy  of  the  right  ventri- 
cle. This  last  condition  distinguishes  it  from  aneurysm  of  the 
aorta.  The  patients  are  usually  cyanotic  and  dyspneie,  and  suffer 
a  good  deal  from  hemoptysis.  The  principal  danger  consists  in 
rupture  and  fatal  hemorrhage.  The  treatment  is  like  that  of 
aneurysm  of  the  aorta  (pages  70  and  71). 


VI.  DISEASES   OF  THE   PLEURA. 


INFLAMMATION  OF  THE  PLEURA  (PLEURISY). 

Ktiologfy. — Inflammation  of  the  pleura  arises  tlirough  the 
agency  of  bacteria.  Whether  such  inflammation  may  occur  as  a 
result  solely  of  chemic  irritants  has  not  yet  been  demonstrated. 
Various  bacteria  may  give  rise  to  inflammation  of  the  pleura, 
though  it  is  by  no  means  invariable  to  detect  bacteria  in  the 
pleural  exudate.  In  addition  to  the  widespread  exciting  agents 
of  inflammation  and  suppuration  (Streptococcus  and  Staphylo- 
coccus pyogenes)  specific  bacteria  have  been  found  in  the  pleural 
exudate,  among  which  may  be  mentioned  Frjinkel's  pneumococci, 
tubercle-bacilli,  typhoid-bacilli,  and  gonococci.  The  Bacterium 
coli  commiuie  has  also  been  found  in  the  pleural  exudate  in 
numerous  instances.  All  of  those  influences  that  were  formerly 
considered  as  causes  of  inflammation  of  the  pleura  are  now  looked 
upon  as  merely  contributory  causes  for  the  infection.  These  in- 
clude exposure  fo  cold,  traumatis-m,  preceding  infectious  disease,  pre- 
ceding disease  of  the  pleura  itself  (titbcrcidosis,  carcinoma),  and  de- 
bilitating diseases  (carcinoma,  tuberculosis,  suppuration ,  chronic 
disease  of  the  kidneys,  chroiuc  disease  of  the  heart,  sj/philitic  ca- 
chexia, scorbutus,  etc.).     At   times   inflammation    of  the   pleura 


INFLAMMATION  OF  THE  PLEURA  153 

arises  by  extension  from  adjacent  disease,  as,  for  instance,  pneu- 
monia, pulmonary  tuberculosis,  gangrene  or  abscess  of  the  lung, 
pericarditis,  inflammation  of  the  ribs,  peritonitis,  etc.  In  some 
cases  no  cause  for  the  inflammation  of  the  pleura  can  be  deter- 
mined {cryptogenetiG  plearisy).  Under  such  conditions  the  pleu- 
risy is  usually  tuberculous,  and  frequently  secondary  to  preexist- 
ing tuberculosis  of  the  tracheobronchial  lymphatic  glands.  Pleu- 
risy occurs  at  all  periods  of  life,  but  most  commonly  between  the 
fifteenth  and  the  fortieth  year.  3Ien  are  attacked  more  commonly 
than  women. 

Anatomic  Alterations. — In  like  manner,  as  in  the  case  of 
pericarditis,  a  distinction  is  made  between  dry  and  moist  pleurisy. 
Dry  pleurisy  is  also  known  as  fibrinous  pleurisy,  because  it  is 
attended  with  the  formation  of  fibrinous  deposits  upon  the  pleura. 
At  first  these  are  thin  and  transparent,  so  that  the  smooth  and 
glistening  surface  of  the  healthy  pleura  appears  as  if  clouded  with 
vapor.  Later,  they  increase  in  thickness,  and  collect  in  consider- 
able amount,  especially  in  the  interlobular  fissures  of  the  lung. 
If  recovery  takes  place,  the  fibrinous  exudate  may  undergo  com- 
plete absorption.  Often,  however,  it  undergoes  organization  into 
connective  tissue,  and  p)hural  adhesions  form,  uniting  the  pul- 
monary and  the  costal  pleura  by  connective-tissue  bands  or  mem- 
branes. At  times  the  adhesions  are  so  extensive  as  completely  to 
obliterate  the  pleural  cavity. 

Moist  pleurisy  is  characterized  by  the  accumulation  of  a  fluid 
exudate  in  the  pleural  cavity.  This  may  be  serous,  purulent,  or 
hemorrhagic  in  nature.  Accordingly,  a  distinction'  is  made  be- 
tween serous  j^leurisy,  purulent  pleurisy  (pyothorax,  empyema), 
and  hemorrhagiG  pleurisy.  Should  2:)utrid  decomposition  take 
place  in  the  pus  through  the  agency  of  putrefactive  bacteria, 
putrid  pleurisy  develops.  The  inflammatory  alterations  in  a  case 
of  moist  pleurisy  usually  begin  with  the  symptoms  of  a  fibrinous 
pleurisy,  and  these  persist  also  at  the  time  of  fluid  effusion. 
This  fact  is  expressed  by  the  designation  serofibrinous  pleurisy. 
The  amount  of  the  exudate  may  reach  ten  liters  and  more,  and  it 
is  therefore  not  surprising  that  the  lung  should  be  compressed 
until  it  is  airless,  while  adjacent  organs  (heart,  diaphragm,  liver, 
spleen)  undergo  more  or  less  marked  displacement. 

Symptoms. — Fibrinous  pleurisy  can  be  recognized  with  cer- 
tainty only  in  the  presence  of  a  pleuritic  friction-murmur.  This 
may  be  of  varying  intensity  and  extent  and  of  variable  duration. 
At  times  it  is  appreciable  only  on  most  careful  auscultation  as  a 
faint  rubbing,  Avhile  in  other  instances  it  gives  rise  to  a  loud, 
creaking  murmur,  which  has  been  designated  as  the  creaking  of 
new  leather,  as  it  has  been  compared  with  the  sounds  generated 
by  the  bending  of  the  sole  of  a  leather  shoe.  It  also  resembles 
the  crackling  of  a  firmly  compressed  snow-ball.    Murmurs  of  con- 


154  RESPIRATORY  ORCIANS 

siderablc  intensity  can  be  felt  as  pleural  fremitus.  At  times  the 
patient  is  conscious  of  rubbing  movements  in  his  chest.  The  mur- 
mur may  also  be  propagated  for  a  slight  distance  from  the  patient. 
At  times  pleuritic  friction-murmurs  are  audible  only  within  circum- 
scribed areas,  not  exceeding  one  or  two  centimeters  in  diameter. 
In  other  instances  they  can  be  heard  over  almost  the  entire  half 
of  the  chest.  At  times  pleuritic  friction-murmurs  persist  for  only 
a  few  hours.  On  the  other  hand,  however,  they  may  continue  for 
many  weeks  and  months.  Not  rarely  they  disappear  after  repeated 
deep  inspiratory  efforts,  because  under  such  conditions  the  layers 
of  the  pleura  move  smoothly  upon  one  another.  After  a  short 
time,  however,  they  generally  reappear. 

Fibrinous  pleurisy  is  usually  associated  with  pleural  pain,  and 
it  is  important  to  determine  its  extent  by  means  of  palpation  in 
order  to  obtain  an  approximate  idea  of  the  inflammatory  area. 
The  pain  is  augmented  considerably  on  cough  and  on  deep  breath- 
ing, in  consequence  of  increased  rubbing  of  the  inflamed  layers 
of  the  pleura.  In  some  instances  fibrinous  pleurisy  discloses 
itself  only  by  pleural  pain,  and  the  diagnosis  of  the  disease  under 
such  conditions  is  exceedingly  difficult.  The  pleural  pain  is 
responsible  for  certain  respiratory  disturbances.  The  respiratory 
movements  are  often  belated  upon  the  affected  side  of  the  chest, 
are  only  superficial,  and  follow  at  intervals.  In  harmony  with 
this  fact  the  respiratory  murmur  is  faint  and  frequently  also 
interrupted  (jerky).  At  times  there  is  marked  dyspnea,  because 
the  respiratory  movements  cannot  take  place  with  sufficient 
freedom.  The  pleural  pain  causes  the  patient,  as  a  rule,  to 
assume  a  passive  attitude  upon  the  healthy  side  of  the  body. 

Patients  with  fibrinous  pleurisy  are  often  harassed  by  dis- 
tressing irritation  of  the  air-passages  and  cough.  They  expectorate 
little  or  none  at  all,  and  suffer  from  so-called  dry  cough.  Pressure 
in  an  intercostal  space  is  usually  followed  by  cough.  Apart  from 
pain  and  disturbed  sleep  tlie  general  condition  may  remain  un- 
changed. At  times,  however,  febrile  movement  occurs,  but  this 
is  usually  moderate.  Among  the  sequclce  of  fibrinous  pleurisy 
pleuritic  adhesions  are  especially  to  be  named.  These  may  cause 
obliteration  of  the  complementary  pleural  spaces,  indicated  by 
respiratory  immobility  of  the  lower  and  median  borders  of  the 
lungs ;  or  they  may  cause  complete  obliteration  of  the  pleural 
cavity,  to  which  dilatation  and  hypertrophy  of  the  heart  may  be 
superadded  in  consequence  of  the  impaired  aspirating  power  of 
the  lungs  upon  the  blood-stream. 

All  forms  of  moist  pleurisy  agree  with  regard  to  tlieir  physical 
alterations.  From  a  diagnostic  point  of  view  dulness  on  percussion 
and  diminution  in  vocal  fremitus  are  especially  distinctive.  We 
shall  now  consider  in  detail  the  individual  methods  of  examination. 
On  inspection  it  will  frequently  be  observed  that  the  patients  prefer 


INFLAMMATION  OF  THE  PLEURA  155 

to  lie  upon  the  diseased  side  of  the  body,  obviously  in  order  that 
respiratory  movement  of  tlie  free,  healthy  side  of  the  chest  directed 
upward  may  be  as  extensive  as  possible.  The  diseased  side  of  the 
chest  participates  but  little,  if  at  all,  in  the  respiratory  movement, 
because  the  pressure  of  tlie  pleural  effusion  prevents  distention 
of  the  thorax  and  of  the  lung.  The  circumference  of  the  chest 
u])on  the  diseased  side  is  increased,  and  not  rarely  the  apex-beat 
of  the  heart  is  displaced  toward  the  healthy  side,  and  the  liver  is 
displaced  downward.  The  type  of  bi^eathing  is  characterized  by 
active  participation  of  the  abdominal  muscles.  Palpation  yields 
important  diagnostic  information,  disclosing  enfeeblement  or  dis- 
appearance of  vocal  fremitus.  The  fluid  that  has  insinuated  itself 
between  the  surface  of  the  lung  and  the  chest-wall  is  quite  capable 
of  preventing  conduction  of  the  voice- waves  from  the  bronchial 
tree  to  the  chest-wall.  If  the  examination  for  vocal  fremitus 
be  made  with  the  border  of  the  hand,  it  is  possible  to  determine 
accurately  the  level  at  which  the  exudate  begins,  from  the  diminu- 
tion in  the  vocal  fremitus.  The  same  information  can  also  be 
gained  by  direct  palpation  of  the  thorax,  because  the  sense  of 
resistance  is  increased  at  the  limits  of  the  exudation.  On  percus- 
sion, dulness  is  detected  within  the  limits  of  the  exudate,  and 
becomes  the  greater  as  the  lower  portions  of  the  thorax  are 
approached,  that  is,  as  the  layer  of  exudate  becomes  the  thicker. 
In  the  majority  of  cases  the  upper  limit  of  dulness  is  highest  at 
the  side  of  the  vertebral  column,  gradually  declining  toward  the 
side  and  the  front  of  the  chest.  This  manifestation  can  be  ex- 
plained by  the  fact  that  in  the  dorsal  decubitus  a  horizontal 
section  passes  through  the  vertebral  column  at  a  higher  level  than 
through  the  anterior  aspect  of  the  chest,  and  that  the  surface  of 
a  pleural  exudate  tends  to  occupy  a  horizontal  position  in  the 
thorax.  Pleural  adhesions  naturally  may  prevent  this  arrange- 
ment. Probably  wavy  elevations  and  depressions  in  the  limits 
of  dulness  upon  the  side  of  the  chest  frequently  depend  upon 
such  adhesions  (Damoiseau's  curves). 

Percussion  of  the  upper  intercostal  spaces  upon  the  anterior  aspect  of 
the  chest  discloses  upon  the  diseased  side  frequently  a  deep-tympanitic  note, 
because  the  pulmonary  tissue  here  is  relaxed.  If  the  pleural  effusion  is 
large,  the  percussion-note  in  this  situation  is  not  rarely  dull-tympanitic, 
and  this  varies  as  the  mouth  is  opened  and  closed — Williams'  tracheal  note 
— in  consequence  of  vibrations  of  air  in  the  bronchus. 

Auscultation  not  rarely  discloses  a  pleuritic  friction-murmur  at 
the  upper  level  of  a  pleural  exudate.  In  other  instances  this  may 
be  heard  only  when  absorption  of  the  exudate  has  begun,  and  the 
pleural  layers  covered  with  fibrinous  deposit  again  come  in  con- 
tact. The  respiratory  murmur  may  be  vesicular,  bronchial,  or 
abolished.  It  retains  its  vesicular  character  as  long  as  the  lung 
is  not  compressed  sufficiently  to  expel  all  of  the  air.    In  the  latter 


156  RESPIRATORY  ORGANS 

event  bronchial  breathing  sets  in.  Over  exceedingly  thick  exu- 
dates no  respiratory  nuirinur  at  all  is  audible.  On  auscultation 
of  the  voice  either  diminished  bronchophony,  (jr  egophony,  is  appre- 
ciable. The  latter  is  observed  especially  over  small  exudates  or 
at  the  upper  level,  and  beside  the  vertebral  column  when  larger 
exudates  are  present.  It  depends  upon  the  fact  that  superficial 
bronchial  tubes  are  readily  compressed,  so  that  the  voice-waves 
for  the  time  being  pass  beyond  the  points  of  compression  and 
reach  the  surface  of  the  chest.  The  influence  of  pleural  exudates 
upon  adjacent  organs  is  noteworthy.  In  the  presence  of  right- 
sided  pleurisy  the  heart  is  at  times  displaced  so  far  to  the  left  that 
its  apex-beat  may  be  present  in  the  midaxillary  line,  while  in  the 
presence  of  left-sided  pleurisy  the  heart  may  be  displaced  to  the 
right  beyond  the  right  mammillary  line.  At  the  same  time  it  should 
be  emphasized  that  the  heart  is  always  so  displaced  to  the  right  tliat 
its  apex  is  directed  to  the  left  and  outward,  so  that  the  pulsating 
part  furthermost  to  the  right  corresponds  to  the  right  border  of 
the  heart.  In  addition  to  the  heart,  the  liver  also  is  frequently 
dis})laced  by  pleural  effusions.  Right-sided  pleural  effusions  dis- 
place the  lower  margin  of  the  liver  at  times  below  the  level  of  the 
umbilicus.  In  the  presence  of  left-sided  pleurisy  the  left  lobe  of 
the  liver  is  at  times  deflected  downward  at  the  round  ligament. 
Left-sided  pleural  effusions,  as  a  rule,  cause  diminution  in  size  or 
obliteration  of  the  semilunar  space,  lying  below  the  heart  and  cor- 
responding to  the  fundus  of  the  stomach,  by  their  weight  push- 
ing the  diaphragm  and  the  stomach  downward.  In  the  same  Avay 
the  spleen,  not  enlarged,  but  displaced,  may  be  accessible  to  the 
fingers. 

The  general  condition  at  times  suffers  surprisingly  little  in  spite 
of  an  extensive  effusion,  and  some  persons  continue  their  M^ork 
uninterruptedly,  although  the  entire  pleural  cavity  may  be  filled 
with  exudate.  Others  complain  of  dyspnea,  stitches  in  the  side, 
and  cough.  In  persons  with  a  ]iurulcnt  exudate  pallor  and  ano- 
rexia often  develop  rapidly.  Not  rarely  distention  of  the  veins  of 
the  neck  and  marked  cyanosis  appear.  Usually  there  is  febrile 
movement  of  varying  degree,  although  the  disease  sometimes  pur- 
sues an  afebrile  course.  The  elimination  of  urine  is  generally  di- 
minished. 

In  accordance  with  the  duration  of  the  disease  a  distinction  is 
made  l)etween  acute,  subacute,  and  chronic  pleurisy,  as  the  disease 
is  protracted  for  as  long  as  four  weeks  or  eight  weeks  or  more. 
The  designation  pleuritis  acutissima  has  been  applied  to  cases  in 
which  the  attack  has  set  in  with  a  chill,  followed  by  high  fever, 
delirium,  meteorism,  and  enlargement  of  the  spleen,  and  has  ter- 
minated fatally,  often  within  a  few  days.  After  absorption  of  a 
pleural  exudate  has  taken  place  complete  recovery  may  ensue. 
Often  areas  of  dulness  remain,  because  considerable  thickening — 


INFLAMMATION  OF  THE  PLEURA  157 

pleuritic  cicatrices — have  formed.  Under  such  conditions  uni- 
lateral retraction  of  the  chest  readily  takes  place,  especially  when 
the  lung  has  been  compressed  by  the  exudate  for  a  long  time,  so 
that  complete  distention  of  the  atelectatic  areas  in  the  lung  is  pre- 
vented by  adhesions.  At  the  same  time  displacement  of  the 
heart  and  the  liver  frequently  takes  place.  The  heart  is  pushed 
unusually  deep  into  the  diseased  chest,  while  the  liver  often 
occupies  an  uncommonly  high  position.  Such  conditions  fail  to 
develop  only  when  the  organs  named  become  fixed  by  adhesions 
in  the  positions  to  which  they  were  displaced  at  the  time  of  the 
exudate.  Patients  who  have  recovered  from  an  attack  of  pleurisy 
suffer  for  a  long  time  from  stitches  in  the  diseased  side  of  the  chest, 
and  from  shortness  of  breath,  conditions  that  probably  depend 
essentially  upon  pleuritic  adhesions. 

The  complications  of  pleurisy  with  eflfiision  depend  upon  the 
amount  and  the  nature  of  the  exudate.  Large  accumulations  of 
fluid  in  the  pleural  cavity  may  by  marked  compression  of  the 
lungs  and  the  heart  give  rise  to  danger  of  suffocation.  At  times 
fatal  syncope  of  sudden  onset  has  been  observed,  occurring  espe- 
cially on  assuming  the  vertical  posture.  Various  conditions  may 
be  responsible  for  such  accidents,  especially  cardiac  weakness 
and  cerebral  anemia,  and  embolism  of  the  pulmonary  artery,  the 
emboli  being  derived  from  cardiac  thrombi  in  the  right  ventricle. 
Much  less  commonly  sudden  distortion  of  the  inferior  vena  cava 
takes  place  in  consequence  of  a  pleural  effusion. 

In  the  presence  of  purulent  pleural  effusions  rupture  of  the  pus 
may  take  place  externally,  or  into  internal  organs.  Rupture  of  pus 
externally  is  preceded  by  bulging  of  the  skin,  with  fluctuation,  the 
protrusion  diminishing  in  size  during  inspiration,  while  it  increases 
in  size  during  expiration,  and  is  capable  of  extinction  on  careful 
pressure.  The  skin  gradually  becomes  reddened,  and  finally  it  may 
rupture,  with  escape  of  the  pus,  sometimes  in  a  strong  stream.  The 
rupture  of  pus  externally  is  designated  empyema  'pleurae  necessitatis. 
If  the  condition  is  left  to  itself,  and  this  would  be  a  grave  mis- 
take, the  discharge  of  pus  may  cease  after  a  time  from  closure  of 
the  fistula.  Renewed  accumulation  of  pus  in  the  pleural  cavity 
may  then  take  place,  and  rupture  again  occurs.  The  patient 
eventually  dies  from  exhaustion  or  amyloid  degeneration.  Em- 
pyema necessitatis  usually  develops  in  the  lateral  inferior  aspects 
of  the  chest,  although  extensive  burrowing  at  times  occurs. 
Rupture  of  purulent  pleural  effusions  into  internal  organs  takes 
place  most  frequently  through  the  lungs.  This  occurrence  will 
be  recognized  by  the  sudden  expectoration  of  large  amounts  of 
pus  (in  mouthfuls),  while  the  exudate  in  the  pleural  cavity  dimin- 
ishes. At  times  the  air-passages  are  so  greatly  filled  with  pus 
that  there  is  danger  of  suffocation,  particularly  if  the  accident 
occurs  during  the   night.      Not   rarely   the   pus   within  the  air- 


158  RESPIRATORY  ORGANS 

passages  acquires  a  putrid  odor,  although  it  may  have  been  odor- 
less in  the  pleural  cavity.  The  expectoration  of  considerable 
amounts  of  pus  may  be  repeated  for  a  varying  length  of  time,  and 
in  varying  amount,  but,  as  a  rule,  the  pus  constantly  reaccumu- 
lates  in  the  pleural  cavity,  and  also  here  threatens  to  cause  death 
by  exhaustion  or  amyloid  disease. 

In  rare  cases  the  discharge  of  pus  does  not  take  place  through  a  pul- 
monary fistula  of  considerable  size,  but  the  pus  is  taken  up  by  the  pulmo- 
nary tissue  as  by  a  sponge  and  is  gradually  expectorated  in  the  form  of 
purulent  sputum. 

Rupture  of  a  purulent  pleural  effusion  into  the  pericardium, 
the  mediastinum,  the  trachea,  the  esophagus,  the  stomach,  the 
intestine,  etc.,  takes  place  but  rarely.  Among  the  complications 
of  pleurisy  pericarditis  may  yet  be  mentioned,  and  this,  experi- 
ence has  shown,  occurs  most  commonly  in  association  with  left- 
sided  pleurisy. 

Diaphraginatic  pleurisy  is  a  special  variety  of  the  disease, 
which,  as  its  name  indicates,  involves  the  diapliragmatic  pleura. 
The  patients  complain  of  severe  pain  in  the  lower  portion  of  the 
chest,  and  there  is  usually  marked  tenderness  upon  pressure  at  the 
lower  border  of  the  chest.  The  irritation  of  the  air-passages  may 
be  considerable.  Often  there  is  painful  eructation,  and  the  act  of 
swallowing  may  be  attended  with  severe  pain  as  soon  as  the  ingesta 
pass  the  esophageal  foramen.  At  times  frequent  vomiting  takes 
place.  Jaundice  has  been  observed  in  cases  of  right-sided  dia- 
phragmatic pleurisy,  and  it  has  been  attributed  to  the  deficiency 
in  the  respiratory  movement  of  the  diaphragm,  which  is  thus  no 
longer  capable  of  causing  expulsion  of  the  bile  from  the  biliary 
passages  in  the  liver.  Dulness  over  the  thorax  may  be  wanting 
because  fluid  may  accumulate  between  the  base  of  the  lung  and 
the  diaphragm  without  coming  in  contact  with  the  chest-wall. 

The  designation  interlobular  pleurisy  is  applied  to  cases  in  which 
fluid  exudate  has  collected  in  the  interlobular  fissures.  The 
exudate  is  usually  purulent,  gives  rise  to  an  area  of  girdle-like 
dulness  around  the  thorax,  and  frequently  ruptures  into  the  lung. 
Muliilocular  pleurisy  is  characterized  by  the  presence  of  a  number 
of  encapsulated  foci  of  exudate.  Usually  the  exudate  is  of  similar 
character  in  all  of  the  foci,  but  it  may  be  that  in  some  the  fluid  is 
serous,  in  others  ])urulent.  Pulsating  pleurisy  is  characterized  by 
pulsation  of  the  diseased  side  of  the  chest,  transmitted  from  the 
heart  to  the  exudate  and  the  chest- wall.  It  is  almost  always  asso- 
ciated ^vith  a  left-sided  purulent  exudate,  though  I  have  observed 
right-sided  pulsating  serothorax  in  a  boy.  Pulsating  pleurisy  may 
be  confounded  with  aneurysm  of  the  aorta,  but  it  is  unattended 
with  vascular  murmurs. 

Diagnosis. — The  recognition  of  a  fibrinous  jyleurisy  is,  as  a 
rule,  easy  if  a  pleuritic  friction-murmur  can  be  heard.     This  might 


INFLAMMATION  OF  THE  PLEURA  159 

at  best  be  confounded  with  snoring  or  sonorous  rdles,  but  these  are 
largely  dependent  upon  eiforts  at  cough,  which  may  cause  their 
disappearance  or  material  alteration  in  them.  The  cJiJferentiation 
between  pleuritic  and  pericarditic  murmurs  is  discussed  on  page  57. 
Should  it  be  necessary  to  make  a  diagnosis  of  fibrinous  pleurisy 
from  the  pleuritic  pain  alone,  care  would  be  demanded  to  avoid 
confusion  with  muscular  rheumatism  and  intercostal  neuralgia.  In 
cases  of  muscular  rheumatism  pain  occurs  especially  when  the 
affected  muscles  are  grasped  between  the  fingers,  and  in  cases  of 
intercostal  neuralgia  the  pain  is  accurately  limited  to  the  course  of 
an  intercostal  nerve.  The  diagnosis  of  a  fluid  exudate  in  the  pleural 
cavity  is  based  principally  upon  dulness  on  percussion,  diminution 
in  vocal  fremitus,  and  displacement  of  adjacent  organs.  Massive 
pneumonia  and  new-growths  of  the  lung  also  give  rise  to  dulness 
and  diminution  in  vocal  fremitus,  but  they  are  unattended  with 
displacement  of  the  heart  and  of  the  liver.  The  differentiation 
between  pleurisy  with  effusion  and  new-groicths  of  the  pleura  may 
be  impossible,  but  the  latter  are  rare.  There  is  but  one  certain 
and  harmless  mode  of  determining  the  nature  of  an  effusion  into 
the  pleural  cavity,  namely,  exploratory  puncture,  which  should  be 
made  in  as  low  an  intercostal  space  as  possible,  by  means  of  a 
sterile  syringe  specially  designed  for  this  purpose.  Encapsulated 
pleurisy  at  times  gives  rise  to  error  in  diagnosis,  for  if  it  be  situ- 
ated near  the  heart,  the  spleen,  or  the  liver,  it  might  be  mistaken 
for  an  enlargement  of  one  of  the  organs  named.  In  the  differen- 
tial diagnosis  especial  consideration  should  be  given  to  the  fact  that 
in  encapsulated  pleurisy  the  outline  of  the  area  of  dulness  is  irreg- 
ular. Difficulties  may  further  arise  in  the  differential  diagnosis 
between  encapsulated  empyema,  and  subphrenic  abscess.  The  diag- 
nosis of  an  accumulation  of  pus  beneath  the  diaphragm  is  based 
upon  the  previous  existence  of  disease  of  the  abdominal  organs, 
the  unusually  high  level  upon  the  anterior  aspect  of  the  chest  of 
the  dulness  corresponding  to  the  accumulation  of  pus,  the  fecal 
odor  of  the  pus  obtained  on  exploratory  puncture,  and  the  exist- 
ence in  the  abscess-cavity  of  positive  pressure  in  inspiration  and 
of  negative  pressure  in  expiration  as  disclosed  by  a  manometer  con- ' 
nected  with  the  cannula  of  a  trocar.  Empyema  pleurce  necessitatis 
finally  may  give  rise  to  confusion  with  cutaneous  or  muscular 
abscesses,  bone-abscesses  of  the  ribs,  and  burrowing  abscesses  of 
the  vertebral  column,  but  under  all  of  these  conditions  respira- 
tory variations  in  the  external  extent  of  the  abscess  are  wanting. 

Prognosis. — ^Nlost  cases  of  pleurisy  terminate  in  recovery, 
and  the  prognosis  is  therefore  favorable.  Unfortunately,  however, 
almost  two-thirds  of  the  cases  are  tuberculous  in  nature,  and  in 
this  fact  resides  the  danger  that  after  a  time  infection  and  tubercu- 
losis will  make  their  appearance  in  other  organs,  most  frequently 
in  the  lungs.    At  times  exudates  are,  by  reason  of  their  great  size, 


160 


RESPIRATORY  ORGANS 


attended  with  danger  of  suffocation.     In  rare  cases  the  general 
condition  may  also  be  seriously  affected. 

Treatment. — The  treatment  of  pleurisy  depends  upon  the 
nature  of  the  infammafiou.  Patients  suffering  from  fibrinous  jjJ (u- 
r/sj/ should  remain  in  bed  and  warm  cataplasms  should  l)e  applied 
to  the  inflamed  area.  If  severe  pain  be  present,  a  subcutaneous 
injection  of  morphin  will  be  required.  Dry  or  wet  cups  also  often 
quickly  relieve  pain.  In  obstinate  cases  derivatives  are  employed, 
as,  for  instance,  mustard-plasters,  cantharidal  plaster,  and  api)liea- 
tions  of  tincture  of  iodiu.  >Serou,s  pleuri.^ij  requires  scarcely  more 
than  expectant  treatment.  3Ioist  warm  applications  to  the  thorax 
and  the  internal  administration  of  potassium  nitrate,  salicylic  acid, 
or  sodium  salicylate — measures  that  increase  the  excretion  of  urine, 
and  thus  favor  absorption  of  the  pleural  exudate — are  usually 
sufficient : 


Or, 


R     Solution  of  potas- 
sium nitrate,  10.0  :  200  {2i  drams  :  6\  fluidounces). 
Dose :  1  tablespoonful  every  two  hours. 


B    Salicylic  acid, 

Make  10  such  starch-capsules. 
Dose :  1  powder  every  three  hours. 

R    Sodium  salicylate. 

Make  10  such  starch-capsules. 
Dose :  1  capsule  every  three  hours. 


1.0  (15  grains). 


1.0  (15  grains). 


I  have  not  observed  any  specific  influence  of  salicylic  acid  and 
its  sodium-combination  upon  serous  pleurisy.  Extensive  experi- 
ence has  convinced  me  that  no  better  and  speedier  results  are 

obtained  from  the  use  of  dcrivatices 
(cups,  leeches,  mustard-plasters),  6W- 
befacients  (potassium  iodid,  applica- 
tions of  tincture  of  iodin  or  of  oint- 
ment of  potassium  iodid  or  of  iodo- 
form), diapihorctics  (pilocarpin,  hot- 
air  baths),  diuretics  (digitalis,  din  re- 
tin),  and  laxatives.  Operative  treat- 
ment for  serous  pleurisy  is  indicated 
only  when  the  effusion  is  so  exten- 
sive from  the  outset  that  death  from 
suffocation  is  threatened  in  conse- 
quence of  displacement  of  the  lungs 
and  the  heart,  or  when  no  diminu- 
tion in  the  effusion  can  be  recognized 
after  the  lapse  of  four  weeks,  or 
when  even  an  increase  in  the  effu- 
sion has  taken  place  in  the  fourth  week  of  the  disease.  For  punc- 
ture of  the  pleural  cavity   I  employ  an  inexpensive  and  simple 


Fig.  24. — Apparatus  for  puncture  of  the 
pleural  cavity. 


INFLAMMATION  OF  THE  PLEURA  161 

apparatus  consisting  of  a  hollow  needle,  a  rubber  tube,  which  is 
interrupted  at  its  middle  by  a  glass  tube  in  order  that  the  flow 
of  fluid  may  be  the  better  observed,  and  a  glass  funnel  and  a 
clamp  (Fig.  24).  The  apparatus  is  filled  with  sterile  water  and 
the  clamp  is  closed.  After  the  skin  has  been  thoroughly  washed 
with  soap,  alcohol,  ether,  and  carbolic-acid  solution  (5.0  :  100),  the 
needle  is  introduced  into  an  intercostal  space,  when  the  funnel  is 
depressed  and  immersed  beneath  the  surface  of  a  solution  of 
carbolic  acid  in  a  glass  vessel  one-quarter  filled,  aud  then  the 
clamp  is  released.  The  pleural  exudate  will  flow  into  the  glass- 
receptacle,  while  entrance  of  air  into  the  pleural  cavity  is  impos- 
sible. I  permit  the  escape  of  fluid  to  continue  until  the  patient 
begins  to  cough  actively  or  complains  of  pain,  or  the  flow  ceases 
spontaneously.  Naturally  the  flow  will  stop  when  the  pressure  in 
the  pleural  cavity  equals  that  of  the  external  atmosphere.  It  is 
impossible  for  negative  pressure  to  develop  in  the  pleural  cavity. 

Rarely  in  cases  of  pleurisy  negative  pressure  exists  in  the  pleural  cavity 
before  puncture  is  undertaken.  Under  such  conditions  the  apparatus  de- 
scribed would  fail  to  secure  evacuation  of  the  pleural  contents,  and  aspirating 
instruments  would  be  required,  among  which  maybe  mentioned  the  syringe 
of  Dieulafoy,  the  apparatus  of  Potain,  and  the  jar  of  Fiirbringer. 

Operative  intervention  is  the  only  appropriate  treatment  for  all 
cases  oi  'purulent  pleurisy,  and  I  should  recommend  resection  of  ribs 
and  incision.  After  puncture  is  performed  fluid  usually  reaccumu- 
lates.  Siphon-drainage  by  the  method  of  Biilau  has  often  been 
employed.  With  the  aid  of  a  trocar  a  rubber  tube  is  introduced 
into  the  pleural  cavity,  while  the  other  extremity  of  the  tube  is 
immersed  beneath  the  surface  of  a  carbolic-acid  solution  (5.0  :  100) 
contained  in  a  suitable  vessel.  In  this  way  provision  is  afforded 
for  constant  discharge  of  the  pus.  Often,  however,  the  formation  of 
pus  continues  for  weeks,  and  resort  must  eventually  be  had  to  rib- 
resection  and  incision.  Putrid  pleurisy  requires  the  same  treatment 
as  purulent  pleurisy,  except  that  after  opening  of  the  thorax  and 
discharge  of  the  pus  disinfectant  and  deodorant  irrigation  should 
be  practised.  In  this  connection  carbolic  acid  and  mercuric  chlorid 
should  be  avoided,  as  fatal  intoxication  may  result  from  rapid 
absorption  of  these  substances,  and  zinc  chlorid  (from  3.0  to 
6.0  :  100),  aluminum  acetate  (from  1.0  to  2.0  :  100),  or  boric  acid 
(2.0  :  100)  should  preferably  be  employed.  Hemorrhagic  pleurisy 
will  require  puncture  only  when  life  is  threatened  by  the  large 
amount  of  blood  present.  After  recovery  from  pleurisy  has  taken 
place  it  is  often  desirable  to  restore  the  distensibility  of  the  previ- 
ously compressed  lungs  by  means  of  pulmonary  gymnastics.  A 
succession  of  deep  inspirations  while  one  arm  is  raised,  and  re- 
peated several  times  daily,  will  suffice.  The  arm  corresponding 
to  the  diseased  side  of  the  chest  should  be  raised,  Pneumatotherapy 
also  should  be  recommended,  particularly  if  the  pleurisy  is  tuber- 
11 


162  RESPIRATORY  ORGANS 

culous  in  nature.    Under  such  conditions  the  patients  should  avoid 

inlmlation  of  dust  and  employment  in  closed  rooms. 

PNEUMOTHORAX. 

Anatomic  Alterations. — Any  accumulation  of  gas  in  the 
pleural  caviti)  is  designated  pneumothorax.  As  a  rule,  fluid  also 
is  present  in  addition  to  the  gas — thus  a  hydrojjueumothorax.  The 
fluid  may  be  serous,  purulent,  putrid,  or  hemorrhagic  (seropneumo- 
ihorax,  pyopjncuniothorax,  heiaopyiieumothorax).  Accordingly  as  gas 
and  fluid  are  freely  movable  in  the  pleural  cavity  or  are  encap- 
sulated by  pleimtic  adhesions,  the  condition  is  spoken  of  as  either  a 
Jree  or  an  encapsulated  pneumothorax  or  hydrojmeurnothorax.  In 
the  cadaver  also  the  existence  of  pneumothorax  and  hydropneumo- 
thorax  is  often  characterized  by  unusual  dilatation  of  the  diseased  side 
of  the  chest  (ectasis),  which'  on  percussion  yields  a  deeply  resonant 
note  like  an  empty  barrel.  On  opening  the  abdominal  cavity  the 
diaphragm  is  usually  found  pushed  downward,  wdth  its  convexity 
projecting  into  this  cavity,  and  the  liver  or  the  stomach  and  the 
spleen  in  consequence  occupying  an  unduly  low  position.  On  jjunc- 
ture  of  the  thorax  gas  generally  escapes  with  a  hissing  sound,  and  often 
diffuses  a  disagreeable  odor  of  hydrogen  sulphid.  The  lung  is,  as 
a  rule,  compressed  and  airless,  being  pushed  upward  and  backward 
at  the  side  of  the  vertebral  column.  At  times  an  opening  in  the 
pulmonarv  pleura  can  be  readily  demonstrated,  through  which  the 
air  has  entered  the  pleural  cavity.  In  other  instances,  however, 
the  opening  has  closed  or  is  concealed  beneath  flbrinous  deposits. 
Under  such  circumstances  a  tube  may  be  introduced  into  the  main 
bronchus,  the  lung  submerged  in  water  and  filled  with  air  through 
the  bronchus,  notice  being  taken  of  the  point  at  which  air-bubbles 
appear.  Displacement  of  adjacent  organs  (mediastinum,  heart,  dia- 
phragm, liver,  stomach,  and  spleen)  is,  further,  distinctive  of 
pneumothorax  and  hydropneumothorax.  It  results  from  the  same 
causes  as  are  operative  in  pleurisy,  but  generally  attains  a  more 
marked  degree. 

Ktiology. — The  conditions  for  the  development  of  pneumo- 
thorax are  ]*rovided  when  the  pleural  cavity  communicates  directly 
with  air- containing  organs  or  with  the  external  air.  This  occurs 
most  commonly  in  connection  with  ulcerative  destruction  in  the  pul- 
monary tissues,  especially  pulmonary  tuberculosis,  gangrene,  and 
abscess  of  the  lung,  and  less  commonly  echinococcus,  tumors,  and 
embolic  infarction  of  the  lung.  It  is  noteworthy  that  at  times 
the  lung  contains  only  a  few  small  tuberculous-caseous  foci  just 
beneath  the  pulmonary  pleura,  which  may  escape  diagnosis,  and 
when  they  rupture  into  the  pleural  cavity  the  impression  may  be 
created  that  the  pneumothorax  was  of  spontaneous  development. 
The  same  statements  apply  to  pneumothorax  associated  icith  alve- 


PNEUMOTHORAX  163 

olar  pulmonary  emphysema,  in  which  at  times  emphysematous 
vesicles  immediately  ])eneath  the  pulmonary  pleura  rupture  in 
consequence  of  insignificant  physical  exertion  or  spontaneously 
during  sleep.  At  times  pneumothorax  develops  in  consequence 
of  injuries  of  the  lungs.  Among  these,  punctured  wounds  are  less 
common  than  excessive  expulsive  efforts,  physical  over-exertion, 
extreme  dyspnea,  severe  cough  and  the  like — conditions  attended 
with  such  increase  in  the  intrapulmonary  air-pressure  that  rupture 
of  the  pulmonary  and  pleural  tissues  takes  place.  Pneumothorax 
may  be  caused  also  by  fracture  of  the  ribs,  if  the  extremities  of 
the  fractured  bone  have  penetrated  the  lung.  At  times  pneumo- 
thorax is  dependent  upon  destructive  processes  in  the  esophagus, 
such  as  are  observed  in  association  with  carcinoma,  abscess,  soften- 
ing, and  unskilful  sounding.  Suppuration  of  the  bronchial  glands 
also  may  give  rise  to  ])neuraothorax,  if  rupture  of  the  pus  takes 
place  simultaneously  into  the  air-passages  and  the  pleural  cavity. 
Destructive  processes  in  the  stomach  and  intestines  (ulceration, 
abscess,  carcinoma)  are  among  the  less  common  causes  of  pneumo- 
thorax. Injuries  of  the  chest-wall  also  (stab-wounds,  gunshot- 
wounds,  and  the  like)  are  not  common  causes  of  pneumothorax, 
because  the  margins  of  the  wound  usually  become  closely  applied 
to  the  cutting  instrument,  Pneumothorax  is  at  times  associated 
with  disease  in  the  pleural  cavity  itself.  Thus  it  may  develop  in 
connection  with  rupture  of  an  empyema  of  the  pleura  through  the 
lungs  or  the  chest-wall.  Xaturally  the  fistula  is  generally  so  con- 
stituted that  while  it  permits  escape  of  the  pus,  it  does  not  permit 
the  entrance  of  air  into  the  pleural  cavity. 

It  is  further  maintained  that  gas  may  develop  spontaneously  in  puru- 
lent pleural  exudates.  The  possibility  must  be  conceded,  as  there  are  bacilli 
with  gas-generating  properties.  V.  Ziemssen  observed  transitory  pneumo- 
thorax develop  after  puncture  of  a  pleural  effusion,  and  he  attributed  the 
condition  to  evaporation  of  gases  from  the  exudate. 

Symptoms. — When  pneumothorax  develops  in  the  presence 
of  healthy  lungs  the  patient  is  seized  with  intense  dyspnea  and  a 
sense  of  suffocation.  Breathing  is  difficult  and  gasping,  the  face 
exhibits  an  expression  of  fear,  cyanosis  develops,  and  an  appear- 
ance of  suffocation  is  presented.  If,  however,  the  lungs  were 
previously  diseased — for  instance,  in  a  case  of  pulmonary  tuber- 
culosis— the  pneumothorax  may  develop  so  insidiously  that  the 
condition  will  be  recognized  only  upon  careful  investigation.  In 
cases  of  pulmonary  tuberculosis  persistent  occupation  of  the  same 
lateral  decubitus  should  arouse  suspicion.  In  addition  to  dilata- 
tion of  the  chest  and  displacement  of  adjacent  organs,  the  metallic 
quality  of  the  physical  phenomena  on  percussion  and  auscultation 
are  especially  distinctive  of  pneumothorax,  while  in  the  presence 
of  hydropneumothorax  movable  dulness  and  splashing  sounds 
are  superadded.     Pursuing  the  several  methods  of  physical  ex- 


164  RESPIRATORY  ORGANS 

aniination  in  detail,  it  is  first  observed  upon  inspection  that  dila- 
tation of  the  chest  (tiioraxectasis)  is  present  on  the  side  on  wiiieh 
the  pneiunotliorax  is  situated,  because  the  negative  pressure  of 
the  luniks  has  disappeared  ;  and  that  the  diseased  side  participates 
but  little  if  at  all  in  the  respiratory  rnoveineut.  Breathing-  is  vis- 
ibly embarrassed,  and  takes  place  with  the  aid  of  the  auxiliary 
muscles  of  respiration.  Often  marked  displacement  of  the  heart 
toward  the  opposite  side  and  unusual  depression  of  the  liver  are 
also  appreciable  to  tiie  eye.  The  patients  lie  upon  the  diseased 
side  of  the  chest  in  order  that  the  other  lung  may  be  as  unre- 
stricted as  possible  in  its  fimction.  Vocal  fremitus  is  diminished 
or  abolished  in  the  area  of  the  air-accumulation,  and,  in  cases  of 
hydropneumothorax  also  in  that  of  the  fluid  accumulation.  Only 
in  places  where  pleural  adhesions  with  the  chest-wall  exist  may 
it  be  maintained  or  even  increased.  If  the  pleural  cavity  con- 
tains gas  and  fluid,  increased  resistance  will  be  readily  appreciable 
at  the  upper  level  of  the  exudate  upon  immediate  palpation  of  the 
chest. 

Measurement  of  the  circumference  of  the  chest  will  disclose  a  difference 
between  the  two  sides  of  as  much  as  10  cm.  and  more.  Tracings  of  a  trans- 
verse section  of  the  chest,  which  can  be  readily  obtained  with  the  aid  of  a 
piece  of  pliable  lead  wire,  applied  to  both  sides  of  the  chest  exactly  at  the 
same  level,  and  then  recording  the  outlines  upon  paper  with  a  lead-pencil, 
will  disclose  distinctly  the  differences  between  the  two  sides. 

The  percussion-note  upon  the  diseased  side  is  unusually  deep 
and  loud,  the  chest-wall  being  but  rarely  so  greatly  distended  by 
the  gas  that  has  escaped  as  to  yield  a  dull  percussion-note.  As 
pneumothorax  is  attended  with  the  presence  of  gas  in  a  large 
cavity  with  smooth  walls,  metallic  percussion-phenomena  will 
be  present.  As  a  rule,  their  development  requires  special  devices 
— namely,  percussion  with  plexor  and  pjleximetcr,  and  auscultatory 
percussion.  In  the  former  a  metallic  plexor  or  the  handle  of  the 
plexor  is  used  instead  of  one  of  rubber,  because  percussion  by 
means  of  hard  substances  will  elicit  by  consonance  the  high  over- 
tones that  give  rise  to  the  metallic  note.  These  can  be  heard 
with  especial  distinctness  when  the  stethoscope  is  applied  to  the 
chest  while  percussion  is  practised,  and  in  this  way  auscultatory 
percussion  is  employed.  Further,  the  metallic  phenomena  can  be 
developed  distinctly  cmly  at  certain  points.  It  will  be  observed 
on  percussion  of  a  free  pneumothorax  that  the  boundaries  of  adja- 
cent organs  (heart,  liver)  are  greatly  displaced.  As  long  as  the 
opening  through  which  gas  has  entered  the  pleural  cavity  remains 
unclosed  percussion  will  yield  a  cracked-pot  sound.  The  percus- 
sion-note also  may  vary  in  ]iitch  accordingly  as  the  mouth  is 
open  or  closed,  becoming  higher  under  the  former  condition — 
so-called  AVintrich's  change  in  pitch — if  the  opening  is  in  imme- 
diate communication  with  a  bronchus  of  considerable  size.     If  the 


PNEUMOTHORAX  165 

opening  is  situated  in  the  chest-wall,  the  cracked-pot  sound  will 
naturally  be  no  longer  heard  on  closure  -with  the  finger,  and  at 
the  same  time  the  percussion-note  will  become  deeper.  In  cases 
of  hydropneumotkorax  the  percussion-phenomena  described  will 
be  present  in  the  upper  portions  of  the  chest  corresponding  to  the 
accumulation  of  gas,  while  in  the  lower,  in  which  fluid  has  accu- 
mulated, dulness  will  be  present.  While  in  the  dorsal  decubitus 
the  upper  limits  of  dulness  are  higher  posteriorly  than  anteriorly, 
they  assume  a  horizontal  level  in  the  sitting  posture,  and  it  is 
especially  characteristic  of  hydropneumothorax  that  the  limits  of 
dulness  vary  in  accordance  with  the  position  of  the  body.  The 
cracked-pot  sound  and  Wintrich's  change  in  pitch  may  also  be 
present  in  cases  of  hydropneumothorax  as  long  as  the  air-fistula 
remains  open,  and  is  situated  above  the  level  of  the  fluid.  If  by 
change  of  position  and  displacement  of  the  fluid  the  fistula  is 
temporarily  closed,  both  the  cracked-pot  sound  and  Wintrich's 
change  in  pitch  disappear,  and  in  this  way  is  provided  a  means 
of  determining  the  position  of  an  air-fistula. 

Biermer  has  called  attention  to  the  fact  that  in  cases  of  hydropneumo- 
thorax the  pitch  of  the  percussion-note  varies  in  accordance  with  the  posi- 
tion of  the  body — so-called  Biermer's  change  in  ipitch.  Usually  the  percus- 
sion-note is  increased  in  pitch  in  the  erect  posture  because  the  exudate,  by 
reason  of  its  weight,  depresses  the  diaphragm,  and  the  diameter  of  the  air- 
cavity  is  thus  increased. 

The  auscultatory  phenomena  elicited  in  a  case  of  pure  pneumo- 
thorax vary.  At  times  no  respiratory  murmur  at  all  is  heard, 
and  it  has,  not  without  reason,  been  maintained  that  unilateral 
dilatation  of  the  thorax,  with  a  deep,  loud  percussion-note  and 
an  absence  of  respiratory  murmur,  is  indicative  of  pneumothorax. 
In  other  instances  metallic  bronchial  breathing  is  audible.  This 
is  especially  distinct,  and  sometimes  is  present  exclusively  during 
expiration.  Bronchial  breathing  occurs  when  the  lung  is  com- 
pressed to  the  degree  of  airlessness,  and  within  tlie  pleural  cavity 
filled  with  gas  it  acquires  metallic  properties  through  consonance. 
Should  rales  develop  within  the  air-passages,  they  also  acquire  a 
metallic  character.  Even  bronchophony,  which  is  diminished  in 
cases  of  pneumothorax,  also  exhibits  a  metallic  character. 

Hydropneumothorax  is  distinguished  by  the  occurrence  of  a 
pleural  splashing  sound  (succussion-sound,  Hippocratic  succus- 
sion),  which  is  generated  on  movement  of  the  body  by  the  impact 
of  the  pleural  fluid  against  the  chest-wall.  Vigorous  agitation 
of  the  patient,  change  in  position  from  one  side  of  the  body  to  the 
other,  rapid  assumption  of  the  vertical  posture,  jumping  upon  the 
feet,  and  the  like,  are  capable  of  generating  the  sound  in  question. 

At  times  the  sound  of  the  falling  drop,  gutta  cadens — meiaJlic  tinJding — 
may  be  heard.  Tliis  results  at  times  on  change  of  posture,  as,  for  instance, 
in  sitting  erect,  from  the  dropping  of  fluid  that  has  accumulated  upon  the 
roughened  surface  of  the  pleura. 


1(36  RESPIRATORY  ORGANS 

As  long,  in  a  case  of  hydropneumothorax,  as  the  air-fistula  in 
the  pulnionarv  pleura  remains  patulous,  expectoration  of  purulent 
material  in  mouthfuls  may  take  j)laee.  The  patients  do  not  ex- 
pectorate often  in  the  course  of  the  day,  but  then  the  sputum  is 
ejected  in  large  amounts,  and  is  not  rarely  expelled  from  both 
mouth  and  nose,  and  in  part  may  enter  the  larynx  and  excite 
vomiting.  Expectoration  takes  place  only  when  sufficient  exu- 
date has  accumulated  in  the  pleural  cavity  to  reach  the  level  of 
the  air-fistula,  and  discharge  into  the  bronchi  has  taken  place. 

The  same  effect  may  be  induced  also  by  certain  positions  of  the 
body.  As  a  rule,  the  patients  persistently  occupy  the  same  lateral 
decubitus,  in  order  to  breathe  with  the  least  possible  restriction 
with  the  free  lung  placed  above.  At  times,  however,  the  patient 
assumes  quite  extraordinary  attitudes  in  order  to  prevent  for  as 
long  as  possible  the  entrance  of  pleural  fluid  into  the  air-fistula 
and  the  air-passages. 

The  duration  of  pneumothorax  and  hydropneumothorax  is  most 
variable.  At  times  death  from  suffocation  results  within  a  few 
hours  after  the  development  of  the  disease,  while  in  other  instances 
the  affection  may  persist  for  years.  Under  the  latter  conditions 
the  patients  may  at  times  be  out  of  bed  and  indulge  in  various 
physical  activities.  In  a  case  of  pneumothorax  gradual  absorption 
of  the  gas,  and  thus  recovery,  may  take  place.  Hydropneumo- 
thorax is  not  rarely  converted  into  a  simple  pleurisy,  the  gas  dis- 
appearing and  the  pleural  effusion  remaining.  In  the  presence  of  a 
purulent  or  a  putrid  hydropneumothorax,  not  treated  by  operative 
measures,  death  may  take  place  from  progressive  asthenia  and 
septicemia. 

Diagnosis. — The  recognition  of  pneumothorax  and  hydro- 
pneumothorax is  usually  easy.  Often  dyspnea  and  threatened 
suffocation  of  sudden  onset  will  attract  attention,  and  in  addition 
tliore  will  be  found  dilatation  of  the  chest,  absence  of  vocal  fremi- 
tus, metallic  phenomena  on  percussion  and  auscultation,  and  in  cases 
of  hydropneumothorax  also  pleural  splashing  sound.  To  decide  the 
nature  of  the  pleural  effusion  in  a  case  of  hydropneumothorax  ex- 
ploratory puncture  will  be  necessary.  The  persistence  of  an  air- 
fistula  in  the  puhnouary  pleura  may  be  recognized  from  the  pres- 
ence of  the  cracked-pot  sound,  and  of  Wintricli's  change  in  pitch, 
and  the  occurrence  of  expectoration  in  mouthfuls.  At  times  a 
valvular  fistula  may  be  temporarily  closed  by  the  excessive  pres- 
sure of  the  gas  in  the  pleural  cavity.  If,  in  addition  to  the 
accumulation  of  gas,  fluid  also  is  present  in  the  pleural  cavity, 
and  if  the  fistula  is  situated  below  the  level  of  tlie  fluid,  gurgling 
murmurs  will  be  audible  if  gas  be  removed  from  the  jileural 
cavity  by  means  of  an  aspirator.  The  sounds  generated  have 
been  designated  puhnonary-jidula,  or  bubbling  murmurs.  These 
result  from  the  entrance  of  air  through  the  again  patulous  fistula 


PNEUMOTHORAX  167 

into  the  pleural  cavity  and  its  passage  upward  through  the  effusion. 
Naturally,  the  same  manifestation  may  be  observed  in  the  pres- 
ence of  an  open  hydro])neumothorax  when  the  air-fistula  is  situated 
beneath  the  level  of  the  pleural  effusion. 

lu  accordance  with  the  character  of  the  air-fistula  four  varie- 
ties of  pneumothorax  may  be  distinguished,  namely  the  open,  the 
closed,  the  valvular,  and  the  transitional.  Open  pneumothorax  is 
provided  with  a  single  opening  through  which  air  enters  the 
pleural  cavity  without  obstruction,  and  can  again  make  its  exit. 
The  pressure  of  the  gas  does  not  exceed  that  of  the  atmosphere, 
and  the  displacement  of  adjaceut  organs  is,  therefore,  usually  not 
excessive.  The  means  for  recognizing  an  open  air-fistula  have 
already  been  described.  Closed  'pneumothorax  is  attended  with  a 
closed  air-fistula.  In  accordance  with  the  amount  of  gas  present 
the  pressure  in  the  pleural  cavity  may  equal  that  of  the  atmo- 
sphere, or  be  less  or  greater  than  this.  If  air  be  permitted  to 
escape  from  the  pleural  cavity,  the  intrapleural  pressure  is  dimin- 
ished and  remains  permanently  unchanged,  as  additional  gas  cannot 
enter.  The  conditions  are  different  in  the  presence  of  valvular 
pneumothorax.  Here  the  pleural  cavity  continues  to  be  filled  with 
gas  until  the  latter  by  excess  of  pressure  causes  closure  of  the 
valvular  fistula.  The  displacement  of  adjacent  organs  is  usually 
quite  considerable.  If  gas  be  evacuated  from  the  pleural  cavity 
by  puncture,  the  fistula  reopens,  and  the  conditions  become  the 
same  as  before  the  puncture.  An  example  of  the  transitional 
variety  of  pneumothorax  is  furnished  by  valvular  pneumothorax, 
which  in  the  presence  of  a  great  excess  in  the  pressure  of  the  gas 
in  the  pleural  cavity  acquires  the  character  of  a  closed,  and  with 
a  diminution  in  the  pressure  presents  those  of  an  open,  pneumo- 
thorax. 

Free  hydropneumothorax  may  be  confounded  with  subphrenic 
hydropneumothorax,  and  with  the  stomach  distended  with  gas  and 
fluid.  Subphrenic  hydropneumothorax  consists  of  a  cavity  filled 
with  pus  and  gas  situated  beneath  the  diaphragm  and  between 
this  and  the  liver  or  the  spleen.  It  is  noteworthy  that  the  devel- 
opment of  this  disorder  has  been  preceded  by  disease  of  the 
abdominal  organs  (stomach,  intestines),  that  the  purulent  masses 
obtained  on  puncture  possess  a  fecal  odor,  and  that,  if  the  respir- 
atory variations  in  the  pressure  of  the  gases  be  studied  with  the 
aid  of  a  manometer,  it  will  be  found  that  the  pressure  is  increased 
during  inspiration,  to  be  diminished  during  expiration,  whereas  in 
cases  of  hydropneumothorax  the  reverse  conditions  prevail.  If 
the  stomach  he  greatly  distended,  ivith  gas,  and  fluid  be  simultane- 
ously present,  the  resonance  of  the  stomach  may  give  rise  to 
metallic  phenomena  in  the  lower  portion  of  the  left  half  of  the 
thorax  on  percussion  and  auscultation,  and  on  agitation  of  the  body 
splashing  sounds  may  appear ;  but  these  phenomena  are  at  once 


168  RESPIRATORY  ORGANS 

modified  when  a  tube  is  introduced  into  the  sttjmacli  and  the 
gases  are  evacuated. 

Encapsulated  hjidropneumothorax  gives  rise  in  part  to  the  same 
manifestations  as  puhnonary  cavities,  but  over  the  latter  the  inter- 
costal spaces  are  usually  retracted,  while  the  vocal  fremitus  is 
increased,  and  succussion-sounds  are  but  rarely  appreciable. 

Prognosis. — The  prognosis  in  cases  of  pncuniothorax  and 
liydropneumotliorax  depends  upon  the  amount  of  gas  that  has 
escaped  into  the  pleural  cavity  and  the  cause  of  the  disorder. 
Quite  considerable  accumulations  of  gas  in  the  pleural  cavity  at 
times  cause  death  by  suffocation  in  the  shortest  possible  time. 
Under  certain  conditions  pneumothorax  and  liydropneumotliorax 
must  even  be  considered  as  fortunate  occurrences,  for  it  is  main- 
tained, not  without  reason,  that  such  events  in  cases  of  pulmonary 
tuberculosis  check  the  progress  of  the  disease. 

Treatment. — In  cases  of  simple  pneumothorax  an  expectant 
attitude  should  be  assumed  for  a  time.  If  serious  dyspnea  be 
present,  alleviation  may  be  sought  by  means  of  subcutaneous  injec- 
tion of  morphin : 

R  Morpliin  hydrochlorate,  0.3  (4j  grains)  ; 

Glycerin, 

Distilled  water,  each,  5.0  (75  minims). — M. 

Dose :  0.5  (8  minims)  subcutaneously. 

In  cases  in  which  the  action  of  morphin  fails,  the  air  in  the 
pleural  cavity  should  be  evacuated  by  puncture,  a  hollow  needle 
and  a  rubber  tube  being  employed  for  the  purpose.  One  end  of 
the  rubber  tube  is  connected  with  the  needle,  while  the  other  is 
submerged  in  a  vessel  containing  a  solution  of  carbolic  acid 
(5.0  :  100).  In  cases  of  open  pneumothorax  puncture  Avould  be 
useless,  as  the  air  at  once  enters  the  pleural  cavity  through  the 
fistula.  In  cases  of  valvular  pneumothorax  also  there  is  a  possi- 
bility of  renewed  accumulation  of  gas,  so  that  permanent  success 
can  be  expected  only  in  cases  of  closed  pneuiiKithorax.  In  cases 
of  hydropneumothorax,  rib-resection  and  incision  into  the  pleural 
cavity  should  be  practised  when  the  pleural  effusion  is  purulent 
or  ])utrid.  Tuberculosis  of  the  lungs  is  not  a  contraindication  of 
operation. 

In  cases  of  putrid  hydropneumothorax  great  care  must  be  observed  in 
irrigating  the  pleural  cavify  us  lonjr  as  the  air-fistula  in  the  lung  remains 
open,  as  the  irrigating  fluid  may  fill  the  air-passages  and  cause  death  by 
suffocation. 

Seropneumothorax  requires  puncture  of  the  pleural  cavity  when 
danger  of  suffocation  is  imminent ;  but  otherwise  an  expectant 
attitude  should  be  assumed.  Internal  remedies  exert  no  influence 
upon  the  disease. 


DROPSY  OF  THE  PLEURA  169 

DROPSY  OF   THE  PLEURA    (HYDROTHORAX) , 

i^tiology. — Hydrothorax  is  characterized  by  tlie  accumula- 
tion of  a  serous  transudate  in  tlie  pleural  cavity,  and  usually  is 
bilateral.  Among  the  causes  are  increased  blood-pressure  in  the 
venous  system  (^hypostatic  edema)  and  anemic  and  cachectic  states 
(cachectic  edema).  Hypostatic  edema  of  the  pleural  cavity  depends, 
as  a  rule,  upon  weakness  of  the  right  ventricle,  such  as  occurs 
especially  in  conjunction  with  valvular  disease  of  the  heart,  myo- 
cardial disease,  disease  of  the  pericardium,  of  the  lungs,  and  of  the 
pleura.  Local  hypostatic  edema  occurs  but  rarely  in  the  pleural 
cavity  when  the  azygos  vein  or  hemiazygos  vein  is  obstructed  by 
pressure  or  by  thrombosis.  Cachectic  edema  develops  in  cases  of 
nephritis,  carcinoma,  suppuration  of  all  kinds,  profound  anemia, 
and  allied  conditions. 

Anatomic  Alterations. — Hydrothorax  occurs  generally  in 
association  with  edema  of  the  skin  and  accumulation  of  transudate 
in  other  serous  cavities.  The  amount  of  fluid  in  the  pleural  cav- 
ity may  reach  several  liters,  and  under  such  conditions  it  is  con- 
siderably greater  in  one  pleural  cavity  than  in  the  other  in  cases 
in  which  the  patient  persistently  occupies  the  same  lateral  decu- 
bitus. The  fluid  is  amber-yellow  or  greenish-yellow  in  color,  and 
transparent,  and  contains  at  most  a  few  flocculi,  Avhich  consist  of 
desquamated  and  swollen  endothelial  cells  or  of  soft  fibrin. 

At  times  the  fluid  presents  a  bloody  appearance  and  in  some  cases  of 
jaundice  an  icteric  hue. 

The  lungs  are  rendered  airless  in  greater  or  lesser  degree  in 
consequence  of  pressure. 

Symptoms  and  Diagnosis. — Hydrothorax  may  develop 
quite  insidiously.  Increasing  compression  of  the  lungs  gives  rise 
to  progressive  dyspnea.  When  the  latter  becomes  excessive,  suffo- 
cation results.  The  diagnosis  depends  upon  the  demonstration  of 
an  accumulation  of  fluid  in  the  pleural  cavity  (dulness,  enfeeble- 
raent  of  vocal  fremitus  and  of  the  respiratory  murmur).  Inflam- 
matory manifestations,  such  as  stitch-like  pain  in  the  side  and 
fever,  are  usually  wanting.  To  distinguish  a  pleural  exudate  and 
a  pleural  transudate  from  each  other  the  specific  gravity  of  the 
fluid  should  be  noted.  A  figure  below  1015  is  indicative  of  a 
transudate  and  a  figure  above  1018  is  indicative  of  an  exudate. 

Prognosis. — The  prognosis  depends  upon  the  nature  of  the 
primary  disorder.  If,  for  instance,  it  is  possible  to  increase  the 
vigor  of  the  heart,  the  hydrothorax  likewise  may  be  made  com- 
pletely to  disappear. 

Treatment. — The  treatment  should  in  the  first  place  be 
directed  to  the  correction  of  the  primary  disorder.  If  the  hydro- 
thorax has  attained  dangerous  prf)portions,  it  should  be  relieved 
by  puncture,  which  may  be  repeated  if  necessary. 


170  RESPIRATORY  ORGANS 

HEMOTHORAX 

Collections  of  blood  in  the  pleural  cavity  may  be  of  traumatic 
origin  or  result  from  rupture  of  aneurysms  of  the  aorta  or  the 
pulmonary  artery,  from  ulceration  of  the  aorta,  tlie  ])uhiionary 
artery,  or  the  pulmonary  vein,  in  consequence  of  tuberculous  or 
gangrenous  destructive  processes  in  the  lungs.  The  blood  in  the 
pleural  cavity  retains  its  fluidity  for  a  long  time,  and  occasionally 
it  induces  secondary  pleurisy. 

The  diagnosis  depends  upon  the  signs  of  an  effusion  of  fluid 
into  the  pleural  cavity,  together  with  symptoms  of  internal  hemor- 
rhage. Besides,  respiratory  disturbances  become  manifest  when 
the  lungs  are  greatly  compressed. 

The  prognosis  depends  upon  the  amount  of  the  hemorrhage, 
and  its  susceptibility  of  control. 

Treatment  should  be  directed  to  the  control  of  the  hemor- 
rhage by  means  of  hemostatics  and  to  the  prevention  of  asthenia 
by  the  use  of  stimulants.  Under  certain  conditions  it  will  be 
necessary  to  remove  the  blood  from  the  pleural  cavity  as  quickly 
as  possible  by  means  of  puncture. 

CHYLOTHORAX, 

The  accumulation  of  chyle  in  the  pleural  cavity  is  an  exceed- 
ingly rare  occurrence.  The  fluid  that  collects  presents  a  milky 
appearance,  yields  an  alkaline  reaction,  contains  sugar  and  a  sugar- 
generating  ferment,  and  microscopic  examination  discloses  the 
presence  of  isolated  lymph-corpuscles.  Care  must  be  taken  to 
avoid  confusion  with  pleural  exudates  containing  fat,  such  as  occur 
especially  in  association  with  carcinoma  of  the  lung.  Exudates 
containing  fat  present  an  abundance  of  fatty  granule-cells. 

The  diagnosis  of  chylothorax  can  be  made  only  by  puncture 
and  chemic  examination  of  fluid  found  in  the  pleural  cavity. 
The  fluid  is  derived  from  the  ruptured   thoracic  duct. 

CARQNOMA  OF  THE  PLEURA. 

Carcinoma  of  the  pleura  is  usually  secondary,  and  develops  at 
times  in  consequence  of  direct  extension  from  adjacent  structures 
(lungs,  mammary  gland,  mediastinum)  and  at  other  times  by  metas- 
tasis from  remote  organs.  While  in  some  cases  innumerable 
miliary  carcinomatous  nodules  are  found  upon  the  pleura,  in 
others  tumor-masses  larger  than  a  fist  are  present.  Often  a  fluid 
effusion  is  present,  at  times  serous,  at  other  times  purulent  or 
hemorrhagic,  and  at  still  other  times  colloid  or  fatty. 

The  diagnosis  of  earcinoma  of  the  pleura  is  difficult.  Miliary 
carcinosis  is  not  rarely  attended  with  intense  dyspnea  and  uncon- 


MEDIASTINAL   TUMORS  111 

trollable  cough.  At  times  carcinoma  of  the  pleura  is  concealed 
behind  the  signs  of  a  pleurisy  with  effusion.  Under  such  condi- 
tions the  presence  in  the  fluid  obtained  on  exploratory  puncture 
of  many  fatty  granular  cells,  and  especially  numerous  multinucle- 
ated cells,  is  significant.  Tumor-masses  of  considerable  size  cause 
dilatation  of  the  heart,  displacement  of  adjacent  organs,  and  diminu- 
tion of  vocal  fremitus  and  of  the  respiratory  murmur,  just  as  does 
pleurisy  with  effusion,  but  the  former  is  distinguished  from  the 
latter  by  the  irregular  outline  of  the  area  of  percussion-dulness. 
At  times  pulsation  is  imparted  to  new-growths  from  subjacent 
arteries,  so  that  the  presence  of  an  aneurysm  is  suggested,  but  the 
diffuse  expansile  pulsation  of  an  aneurysm  is  wanting.  Numerous 
complications  may  be  superadded  in  consequence  of  pressure  upon 
and  constriction  of  the  esophagus  and  adjacent  vessels. 

The  prognosis  is  unfavorable. 

The  treatment  consists  in  the  relief  of  the  most  prominent 
symptoms. 

ECHINOCOCCUS  OF  THE  PLEURA, 

Echinococcus-cysts  occur  but  rarely  in  the  pleural  cavity. 
They  may  rupture  into  the  pleural  cavity  from  the  lungs  or  the 
liver,  or,  less  commonly,  they  may  develop  primarily  in  the  pleural 
cavity.  At  times  they  give  rise  to  pleurisy  especially  purulent  in 
character.  They  occasion  dulness  on  percussion,  with  enfeebled 
vocal  fremitus  and  respiratory  murmur,  the  dulness  being  charac- 
terized by  its  irregular  limits.  At  times  they  cause  protrusion 
externally,  and  finally  they  rupture  in  the  same  direction.  If 
puncture  be  deemed  necessary,  it  would  be  important  to  examine 
the  fluid  obtained — which  will  be  found  free  from  albumin — for 
the  presence  of  echinococcus-scolices,  booklets,  and  laminated  mem- 
brane. The  patients  often  complain  of  stitch-like  pain  in  the  side 
and  dyspnea.  The  condition  is  only  susceptible  of  treatment  by 
operative  measures. 


VII.    DISEASES   OF  THE   MEDIASTINUM. 


MEDIASTINAL  TUMORS. 

Anatomic  Alterations. — Mediastinal  tumors  include  new- 
growths  of  all  kinds  in  the  mediastinum.  These  are  most  com- 
monly situated  in  the  anterior  mediastinum.  They  are  associated 
with  especial  frequency  with  diseases  of  the  lymjDhatiG  glands 
(lymphoma,  sarcoma,  carcinoma).  Much  less  commonly  they 
arise  from  the  mediastinal  connective  tissue  (fibroma,  lipoma).     At 


172  RESPIRATORY  ORGANS 

times  they  are  dependent  upon  disease  of  the  thymus  gland  (sar- 
coma). Sometimes  osteomata  arise  from  the  sternum.  Substernal 
struma  also  is  inchided  among'  mediastinal  tumors.  In  rare  instances 
dermoid  cysts  and  echinococci  have  been  observed  in  the  medias- 
tinal space.  At  times  new-urowths  extend  from  adjacent  structures 
— as,  for  instance,  the  pericardium — to  the  mediastinum,  where 
they  attain  considerable  and  conspicuous  proportions  during  life. 

Ktiology. — In  many  instances  no  cause  whatever  for  the 
development  of  mediastinal  tumors  can  be  elicited.  In  other 
instances  traumatism  is  assigned  as  the  cause.  At  times  enormous 
enlargement  of  lymphatic  glands  takes  place  in  the  sequence  of 
scrofufosis,  leukemia,  pseudoleukemia,  and  syphilis.  Experience  has 
shown  that  mediastinal  tumors  occur  more  commonly  in  men  than 
in  women.  They  appear  mostly  between  the  twentieth  and  the 
thirtieth  year  of  life. 

Symptoms  and  Diagnosis. — Mediastinal  tumors  are  at- 
tended principally  Avith  two  groups  of  symptoms — in  the  first  place 
with  abnormal  areas  of  dulness,  and  in  addition  with  pressure  upon 
and  displacement  of  adjacent  organs.  Both  groups  of  symptoms  may 
be  present  together,  or  one  alone  may  be  encountered.  Abnormal 
areas  of  dulness  occur  most  commonly  over  the  manubrium  sterni, 
and  it  appears  noteworthy  in  this  connection  that  on  percussion,  in 
contradistinction  from  the  normal  conditions,  the  manubrium  sterni 
yields  a  duller  note  than  the  body  of  the  sternum.  In  the  presence 
of  mediastinal  tumors  of  considerable  size  the  area  of  dulness 
extends  fir  beyond  the  borders  of  the  sternum,  and  if  the  new- 
growth  has  invaded  the  lungs  throughout  a  large  extent,  the  greater 
portion  of  the  anterior  aspect  of  the  chest  may  yield  dulness  on 
percussion.  Further,  the  marked  resistance  on  percussion  is  often 
conspicuous.  Tumors  in  the  posterior  mediastinum  give  rise  to 
abnormal  areas  of  dulness  at  the  side  of  the  vertebral  column. 
In  this  situation  also  the  dulness  may  attain  a  considerable  extent. 
Pressure-phenomena  and  displacement  involve  especially  the  circu- 
latory and  respiratory  organs  and  the  nerves.  At  times,  however, 
the  chest  itself  may  be  distorted  in  consequence  of  pressure,  and 
particularly  tlie  manubrium  sterni  may  undergo  marked  protrusion 
forward.  At  times  the  bony  portions  of  the  thorax  may  be  eroded, 
and  the  new-growth  may  l)e  situated  directly  beneath  the  skin.  At 
the  same  time  it  may  be  the  seat  of  pulsation  transmitted  from  sub- 
jacent arteries,  but  the  movement  ahvays  consists  only  in  simple 
elevation  and  depression,  and  never,  in  contradistinction  from  an 
aneurysm,  in  expansile  pulsation.  The  heart  is  often  displaced  down- 
ward and  outward  l)v  mediastinal  tumors,  so  that  the  apex-beat  may 
be  situated  below  the  left  fifth  intercostal  sjiace,  and  outside  the  left 
mam  miliary  line.  Xot  rarely  the  increased  extent  of  the  apex- 
beat  is  noteworthy,  resulting  from  the  greater  application  of  the 
heart  to  the  anterior  wall  of  the  chest.     Often  marked  fulness  and 


INFLAMMATION   OF  THE  MEDIASTINUM  173 

tortuosity  of  some  cutaneous  veins  are  noticeable  if  pressure  has  been 
exerted  upon  the  veins.  At  times  such  vessels  are  apparent  beneath 
the  skin  of  the  chest,  at  other  times  upon  one  side  of  the  neck  and 
face,  at  still  other  times  upon  one  arm.  Usually  cyanosis  is  associ- 
ated, and  frequently  also  circumscribed  edema  of  the  skin.  Pres- 
sure upon  arteries  may  give  rise  to  retardation  and  reduction  in  the 
size  of  the  pulse  upon  one  side  of  the  body.  Cardiac-systolic  mur- 
murs due  to  pressure  may  also  be  present.  At  times  signs  of  uni- 
lateral or  bilateral  bronchostenosis  appear.  Cyanosis  and  intense 
dyspnea  are  occasionally  due  to  pressure  upon  the  lungs  or  to 
extension  of  the  new-growth  to  the  pulmonary  tissue.  Not  rarely 
attacks  of  increased^  dyspnea  occur,  without  the  development  of 
demonstrable  alteration  in  the  objective  conditions.  Large  medias- 
tinal tumors  may  cause  displacement  of  the  liver  and  the  spleen. 
Obstruction  of  the  esophagus  also  may  result  from  pressure.  Fre- 
quently p«ra7y.sts  of  the  recun'ent  laryngeal  nerve  is  caused  by  pres- 
sure. This  is  at  times  unilateral,  at  other  times  bilateral,  or  it  may 
be  at  first  unilateral  and  subsequently  become  bilateral.  Pressure 
upon  the  cervical  symjiathetic  gives  rise  to  pupillary  changes.  Uni- 
lateral irritation  of  the  sympathetic  causes  dilatation,  paralysis, 
and  contraction  of  the  pupil.  Symptoms  o^  paralysis  of  the  vagus 
also  occur,  and  are  manifested  by  unusual  slowness  of  action  of  the 
heart  (irritation  of  the  vagus)  or,  in  the  presence  of  paralysis  of 
the  vagus,  by  acceleration  of  the  action  of  the  heart.  Attacks  of 
spasm  of  the  esophagus,  eructation,  and  vomiting  have  also  been 
attributed  to  irritation  of  the  vagus.  Irritation  of  peripheral 
nerves  may  give  rise  to  severe  neuralgia.  The  course  of  mediastinal 
tumors  is  generally  chronic  and  fatal.  Death  results  most  com- 
monly from  suffocation,  though  at  times  from  progressive  asthenia. 

Prognosis. — Mediastinal  tumors  require  a  serious  prognosis 
in  all  instances,  although  in  rare  cases  the  possibility  of  recovery 
cannot  be  excluded,  as,  for  instance,  in  those  of  syphilis. 

Treatment. — Causal  treatment  is  probably  applicable  only  in 
cases  of  syphilis,  and  then  consists  in  the  external  and  internal 
employment  of  preparations  of  iodin  and  of  mercury.  Opportu- 
nity for  operative  intervention  will  be  but  rarely  afforded.  Accord- 
ingly, symptomatic  treatment  alone  will  usually  be  available.  It 
often  becomes  necessary  to  relieve  the  suflFerings  of  the  patient  as 
much  as  possible  by  means  of  narcotics,  especially  subcutaneous 
injections  of  morphin. 

INFLAMMATION    OF   THE   MEDIASTINUM 
(MEDIASTINITIS). 

Inflammation  of  the  mediastinum  is  one  of  the  rarest  of  dis- 
eases. It  occurs  either  as  a  chronic  mediasfinitis,  with  cicatricial 
thickening  of  the  mediastinal  connective  tissue,  or  as  an  acute  medi- 


1 74  RESl'IRA  TOR  Y  One  A  y.s 

adiiiifis,  Avhieli  mav  g-ivo  rise  to  a  circumscribed  mediadinal  abscess. 
Among  causative  factors  traumatisrn,  exposure  to  cold,  infectious 
diseases,  and  injiainmation  of  adjacent  organs  are  mentioned. 

Acute  hicdiastinitis  is  attended  witli  .sejjfic  manifestations  (chiWsy 
fever).  The  patients  frequently  complain  of  a  sense  of  pressure 
and  pain  beneatii  the  sternum,  and  not  rarely  also  of  difficulty  in 
swallowing.  The  skin  over  the  sternum  exhibits  redness  and 
inflammatory  collateral  edema.  Should  a  mediastinal  abscess 
develop,  dulness  over  the  manubrium  sterni  appears  if  the  accu- 
mulation of  pus  is  situated  in  the  anterior  mediastinal  space. 
Kupture  of  the  pus  may  take  place  internally  or  externally,  and 
in  the  latter  event  the  pus  may  find  its  way  beneath  the  skin  of 
the  neck  or  to  some  remote  point  in  conseqiience  of  burrowing. 
At  times  large  blood-vessels  are  eroded  by  the  suppurative  pro- 
cess, and  fatal  hemorrhage  results. 

The  diagnosis  often  remains  doubtful  during  life.  In  the 
first  place,  antiphlogistics  (ice-bag,  leeches,  inunctions  of  mercu- 
rial ointment)  will  be  employed,  and  if  the  pus  be  not  too  deeply 
situated  incision  may  be  practised. 

The  dangers  of  chronic  mediastinitis  consist  principally  in  in- 
volvement, distortion,  and  angulation  of  large  vessels  or  the 
esophagus  or  bronchial  tubes.  At  times  they  give  rise  to  paral- 
ysis of  the  recurrent  laryngeal  nerve. 

Treatment  is  futile. 

INTERSTITIAL  MEDIASTINAL  EMPHYSEMA, 

Accumulation  of  r/as  in  the  connective  tis.w.e  of  the  rncdiastincd 
space  may  result  from  rupture  of  air-containing  organs  (lung, 
eso})hagus,  stomach,  intestine)  into  the  mediastinum.  It  occurs 
frequently  in  association  with  interstitial  emphysema  of  the  lungs, 
and  is  then  dependent  upon  the  same  causes.  The  principal 
manifestations  include  a  clear  percussion-note  over  the  sternum, 
displacement  of  the  heart  outward  toward  the  left,  and  of  tiie 
liver  downward,  and  crepitating  and  clacking  rales  with  the 
movements  of  the  heart.  There  may  be  dyspnea  and  a  sense 
of  oppression. 

The  treatment  is  purely  symptomatic. 


PART  III. 

DISEASES    OF   THE    DIGESTIVE 
ORGANS. 


DISEASES  OF  THE  MOUTH. 


CATARRHAL  STOMATITIS. 

Htiology. — Like  most  catarrhal  conditions  of  mucons  mem- 
branes, catarrh  of  the  mucous  membrane  of  the  mouth  may  be 
due  to  mechanical,  thermic,  toxic,  or  infectious  causes.  It  may,  in 
addition,  result  from  the  extension  of  adjacent  inflammation. 
Among  mechanical  etiologic  factors  the  sharp  edges  of  teeth  may 
be  especially  mentioned.  Thermic  injurious  agencies  include 
burns  due  to  hot  articles  of  food.  Toxic  stomatitis  occurs  not  only 
in  the  sequence  of  ingestion  of  corrosive  acids,  alkalies,  and  other 
poisons,  but  also  in  drinkers  and  smokers  from  the  irritation 
caused  by  alcohol  and  tobacco.  Catarrhal  stomatitis  occurs  in 
infants  if  the  mouth  is  not  cleansed  or  is  but  imperfectly  cleansed 
of  remnants  of  milk,  the  fermentation  of  which  then  gives  rise  to 
irritation  of  the  mucous  membrane ;  or  if  the  cleansing  of  the 
month  is  effected  by  means  of  coarse  cloths  and  with  too  much 
vigor.  Under  the  conditions  last  named  mechanical  irritation  of 
the  mucous  membrane  of  the  mouth  also  takes  place.  At  times 
catarrhal  stomatitis  arises  after  the  internal  or  external  employ- 
ment of  certain  medicaments,  as,  for  instance,  potassium  iodid  or 
bromid,  arsenic,  and  mercury.  Infectious  catarrhal  stomatitis  is 
frequently  of  secondary  origin,  and  develops  in  the  course  of 
other  infectious  diseases  (typhoid  fever,  measles,  scarlet  fever, 
small-pox,  syphilis).  Little  is  known  with  regard  to  primary 
infectious  catarrhal  stomatitis.  It  may  arise,  for  instance,  by 
inoculation  of  gonococci  upon  the  mucous  membrane  of  the 
mouth.  tStomatitis  arising  by  extension  from  adjacent  disease 
occurs  ^vith  especial  frequency  in  the  sequence  of  diseases  of  the 
teeth.  In  infants  it  accompanies  the  irruption  of  the  teeth. 
Catarrhal    conditions   of  the   nares,  the   pharynx,  and   especially 

175 


176  DIGESTIVE  onaAxs 

the  stomach,  frequently  give    rise  to  secondary  catarrh   of  the 
mucf)ns  nieinhrano  of  th(!  mouth. 

Symptoms,  Anatomic  Alterations,  Diagnosis,  and 
Prognosis. — In  accordance  with  the  course  of  the  disease  a 
distinction  shouhl  be  made  between  acute  and  chronic  catarrhal 
stornatitiii.  Tiie  hitter  occurs  especially  in  drinkers  and  smokers. 
At  times  the  condition  is  clrcumscribefJ,  at  other  times  (Uffasc. 

Acute  catarrhal  stoniatiiis  is  characterized  by  redness,  swelling, 
and  increased  heat  of  the  diseased  parts.  At  times  the  lymph- 
follicles  of  the  mucous  membrane  are  greatly  swollen,  and  supcr- 
iicial  loss  of  tissue  may  take  place.  The  patients  complain  prin- 
cipally of  a  sense  of  burning  and  even  of  pain  in  the  mouth,  and 
infants  frecpiently  dig  their  fingers  into  the  mouth.  The  latter 
also  not  rarely  cease  nursing  in  the  midst  of  the  act,  or  they  refuse 
nourishment  altogether  on  account  of  the  pain.  The  secretion  of 
saliva  is  increased  in  consequence  of  reflex  irritation.  In  children 
the  saliva  usually  pours  out  of  the  mouth,  often  irritating  the 
external  integument  and  giving  rise  to  linear  redness  correspond- 
ing to  the  course  followed  by  the  secretion.  In  adults,  on  the 
other  hand,  there  is  increased  frequency  in  the  act  of  swallowing. 
The  tongue,  as  a  rule,  presents  a  grayish  or  yellowish,  even  a 
brownish  coating,  consisting  of  remnants  of  food,  desquamated 
and  fattily  degenerated  epithelial  cells,  bacteria,  especially  lepto- 
thrix-threads,  but  containing  at  times  also  cholesterin-plates  and 
lime-crystals.  At  the  margins  of  the  tongue  and  also  upon  the 
mucous  membrane  of  the  cheeks  the  impressions  of  the  teeth  are 
visible  in  the  form  of  grooved  depressions.  Often  a  disagreeable, 
fetid  odor  emanates  from  the  mouth.  Frequently  complaint  is 
made  also  of  a  disagreeable  and  pasty  taste.  At  times  there  is 
increased  thirst.  Elevation  of  temperature  occurs  now  and  then 
in  infants.  The  disease  often  terminates  within  a  few  days,  and 
is  unattended  with  serious  sequelse. 

In  cases  of  chronic  catarrhal  stomatitis  also  the  mucous  mem- 
brane presents  an  altered,  and  usually  a  brownish-red  color. 
Often  the  epithelium  is  thickened  and  turbid,  so  that  grayish- 
white  spots  form.  At  times  painful  fissures  occur  in  the  mucous 
membrane,  but  apart  from  these  a  sense  of  burning  and  of  sore- 
ness in  the  mouth  is  often  cotnplained  of.  Alcoholics  and  smokers 
not  rarely  suffer  from  chronic  catarrhal  stomatitis  throughout  life, 
but  the  disorder  is  quite  a  harmless  one. 

Treatment. — The  first  indication  is  the  removal  of  the  causa- 
tive factors,  causal  treatment,  and  in  addition  the  mouth  should 
be  rinsed  after  each  meal  with  potassium  chlorate  (5.0  :  200).  In 
infants  the  mouth  should  be  carefully  cleansed  after  each  meal 
with  the  solution  named  by  means  of  a  bit  of  linen.  Applica- 
tions of  mercuric  chlorid  (0.5  :  50)  or  argentic  nitrate  (1.0  :  50)  have 
been  recommended  for  chronic  catarrhal  stomatitis. 


ULCERATIVE  STOMATITIS  177 

ULCERATIVE  STOMATITIS, 

Symptoms,  Anatomic  Alterations,  Diagnosis,  and 
Prognosis. — Ulcerative  stomatitis  is  characterized  by  gangren- 
ous destruction  of  the  mucous  membrane  of  the  mouth,  especially 
that  of  the  gums.  The  disease  begins  as  a  rule  with  marked  red- 
ness and  swelling  of  the  gums.  Most  frequently  the  gums  of  the 
lower  jaw,  especially  around  the  left  incisor  tooth,  are  first  affected. 
The  gums  are  unusually  soft,  and  bleed  readily  on  the  slightest 
touch.  Eventually  they  are  transformed  into  a  necrotic  brownish 
or  blackish  mass,  which  on  microscopic  examination  is  found  to 
contain  round  cells,  red  blood-corpuscles,  at  times  algae  and  infu- 
soria, but  especially  innumerable  bacteria.  At  times  the  gum& 
are  so  completely  destroyed  that  the  teeth  are  loosened,  and  can 
be  removed  with  the  fingers  without  difficulty  and  without  pain. 
The  disease  of  the  gums  appears  only  in  such  situations  where 
there  are  teeth.  If  any  teeth  are  absent,  the  gums  in  those  situa- 
tions escape.  Edentulous  infants  are  not  attacked  by  ulcerative 
stomatitis. 

The  patients  complain  of  pain  in  the  mouth,  which  is  increased 
especially  on  the  ingestion  of  food.  The  secretion  of  saliva  is 
increased  by  reflex  irritation.  The  saliva  flows  from  the  mouth, 
is  often  streaked  with  blood,  and  gives  off"  a  disagreeable  odor. 
The  skin  of  the  chin  is  frequently  reddened  in  streaks  by  the 
saliva  and  slightly  inflamed.  The  sleep  is  often  disturbed  in  con- 
sequence of  the  excessive  flow  of  saliva,  which  may  enter  the 
larynx  or  be  discharged  upon  the  pillow.  Patients  usually  exhale 
a  horribly  offensive  odor  from  the  mouth,  which  permeates  the  air 
of  the  room  within  a  short  time,  and  becomes  evident  even  to  the 
patient,  causing  a  distaste  for  food  and  drink.  Usually  adjacent 
lymph- glands,  particularly  the  submaxillary,  undergo  inflammatory 
swelling.  The  patients  not  rarely  acquire  within  a  remarkably 
short  time  a  grayish,  almost  cachectic  appearance,  and  they  suffer 
from  unusual  languor.  The  bodily  temperature  generally  remains 
unaltered. 

The  disease  almost  always  terminates  in  recovery,  although  a 
patient  under  my  observation  died  in  consequence  of  septicemia. 
A  distinction  has  been  made  between  acute  and  chronic  ulcerative 
stomatitis,  accordingly  as  the  disease  terminates  within  one  or  two 
weeks  or  after  the  lapse  of  several  months.  In  the  absence  of 
sufficient  care  in  treatment  adhesions  may  form  between  opposed 
ulcerated  surfaces — as,  for  instance,  between  the  mucous  membrane 
of  the  cheek  and  the  border  of  the  tongue — and  which  often  can 
be  removed  only  with  difficulty  by  operative  means.  At  times  the 
necrosis  extends  to  the  lower  jaw. 

i^tiology. — A  distinction  should  be  made  between  infectious 
and  toxic  ulcerative  stomatitis.     The  infectious  variety  often  occurs 

12 


178  DIGESTIVE  ORGANS 

endcmically,  as,  for  instance,  in  l)arraeks,  jails,  orphan-asylums, 
boarding-sciiools.  Over-crowded,  poorly  ventilated,  and  damp 
dwellings  favor  its  development,  as  do  likewise  deficiency  of  food 
and  neglect  in  the  care  of  the  mouth.  The  conditions  named 
render  it  explicable  that  the  disease  has  been  encountered  almost 
exclusively  among  the  poorer  classes.  Ulcerative  stomatitis  is 
observed  most  commonly  in  children.  Anemic,  rachitic,  scrofu- 
lous, and  otherwise  debilitated  children  display  a  marked  predis- 
position to  the  disease.  The  disorder  occurs  most  commonly  in  the 
summer  months. 

Specific  bacteria  are  as  yet  unknown  in  the  etiology  of  ulcerative  stoma- 
titis. The  Staphylococcus  pyogenes  aureus  has  been  obtained  from  the 
necrotic  tissue. 

Toxic  ulcerative  stomatitis  may  be  induced  by  mercurial  prepa- 
rations, either  because  these  have  been  employed  in  excessive 
doses  or  because  the  individuals  are  unduly  susceptible  to  the 
action  of  mercury. 

Treatment. — Causal  treatment  will  require  the  withdrawal 
of  mercurial  preparations,  the  provision  of  healthy  dwellings,  and 
food  sufficient  in  amount  and  variety.  Symptomatically,  irrigation 
of  the  mouth  after  each  meal  with  potassium  chlorate  (5.0  :  200) 
may  be  recommended.  The  food  should  consist  especially  of  milk, 
weak  wine,  beer,  broth,  cocoa,  coffee  with  milk  and  eggs.  Hot  and 
solid  articles  of  food  should  be  avoided  on  account  of  the  pain  in 
the  mouth. 

APHTHOUS  STOMATITIS. 

Sjrmptoms,  Anatomic  Alterations,  Diagnosis,  and 
Prognosis. — Aphtha?  appear  as  yellowish  or  whitish  deposits 
upon  the  mucous  membrane  of  the  mouth,  which  are  surrounded 
by  a  red  hyperemic  zone,  and  in  contradistinction  from  masses  of 
casein  or  of  thrush  cannot  be  detached  with  the  finger.  They 
occur  with  especial  constancy  njwn  the  anterior  aspect  of  the 
tongue,  and  upon  the  line  of  reflection  from  the  gums  to  the 
mucous  membrane  of  the  lips.  Their  average  size  is  between  that 
of  a  lentil  and  that  of  a  pea.  They  are  at  times  roundish  in 
shape,  but  by  coalescence  they  may  acquire  an  irregular  shape. 
Their  number  is  subject  to  wide  variations. 

The  patients  complain  of  a  sense  of  burning,  and  even  of  pain 
in  the  mouth.  Infants,  therefore,  often  suddenly  cease  nursing,  or 
altogether  refuse  nourishment.  There  is  usually  increased  secre- 
tion of  saliva  from  reflex  irritation.  The  general  condition,  as  a 
rule,  exhibits  no  alteration.  In  the  course  of  a  few  days  the  spots 
disappear,  becoming  smaller  and  smaller  by  absorption  or  by  curl- 
ing up  at  the  margins,  then  becoming  detached  and  exfoliated,  and 
leaving  a  shallow  ulcer,  which  within  a  short  time  becomes  covered 


THRUSH  179 

with  epithelium,  and  heals  without  loss  of  structure.  The  disorder 
usually  lasts  from  one  to  two  weeks ;  at  times,  in  consequence  of 
repeated  relapses,  somewhat  longer.  It  is  unattended  with  danger. 
At  times  there  may  be  retention  of  saliva  in  the  salivary  glands  if 
aphthae  develop  at  the  orifice  of  a  salivary  duct  and  cause  obstruc- 
tion. Exceptionally  acute  nephritis  has  been  observed  in  the 
sequence  of  aphthous  stomatitis. 

Microscopic  examination  of  the  spots  discloses  the  j^resence  of  fibrin 
admixed  with  a  small  number  of  round  cells  and  bacteria  (Staphylococcus 
pyogenes  albus  and  aureus,  the  pneumococcus  of  Friedlander,  the  diplo- 
coccus  of  Stooss).  It  is  assumed  tliat  aphthous  stomatitis  is  an  infectious 
disease,  and  that  bacteria  cause  coagulation-necrosis  of  the  epithelial  cells 
of  the  buccal  mucous  membrane,  so  that  fibrinous  coagulation  can  take 
place  in  the  exudate.  The  deeper  layers  of  the  mucous  membrane  are  not 
involved  in  the  inflammatory  process. 

Ktiology. — Like  most  varieties  of  inflammation  of  the  mouth, 
aphthous  stomatitis  occurs  with  especial  frequency  in  children,  par- 
ticularly anemic,  rachitic,  and  scrofulous  children.  Any  irritation 
of  the  buccal  mucous  membrane  may  be  followed  by  the  develop- 
ment of  aphthous  stomatitis.  In  infants  it  is  observed  in  associa- 
tion with  the  irruption  of  the  teeth,  with  uncleanliness  of  the  mouth, 
and  with  irritation  of  the  buccal  mucous  membrane  from  improper 
cleansing  of  the  mouth.  Aphthous  stomatitis  may  be  associated 
with  the  most  varied  diseases  of  the  mouth  (catarrhal  stomatitis, 
ulcerative  stomatitis,  thrush).  It  may  result  also  from  the  irrita- 
tion excited  by  sharp  projections  of  teeth.  In  women  the  disease 
sometimes  appears  at  the  menstrual  period  or  during  pregnancy  or 
lactation.  At  times  it  appears  in  the  course  of  infectious  diseases 
(typhoid  fever,  pneumonia,  pulmonary  tuberculosis,  diphtheria). 
Occasionally  aphthous  stomatitis  occurs  epidemically,  particularly 
in  the  summer  months,  and  instances  of  contagion  may  also  be 
observed. 

Treatment. — In  the  first  place,  all  obvious  causes  should  be 
removed — causal  treatment.  In  addition  the  mouth  should  be 
rinsed  after  each  meal  with  potassium  chlorate  (5.0  :  200)  or,  in 
the  case  of  small  children,  brushed  or  carefully  swabbed. 

THRUSH  (STOMATITIS  OIDICA), 

Symptoms,  Anatomic  Alterations,  Diagnosis,  and 
Prognosis. — Thrush  is  attended  with  the  formation  of  whitish  or 
yellowish  deposits  upon  the  mucous  membrane  of  the  mouth,  which 
can  be  readily  detached  with  the  finger  or  a  hard  object.  Micro- 
scopic examination  discloses  the  presence  of  a  readily  recognized 
bacterium.  The  thrush-fungus,  O'idium  albicans,  belonging  to  the 
budding  fungi,  forms  in  part  septate  thallus-filaments,  in  part 
roundish  or  elongated  spores  (Fig.  25).  The  tip  and  margins  of 
the  tongue  are  as  a  rule  attacked  first,  although  the  proliferation 


180 


DIGESTIVE  ORGANS 


may  extend  to  the  mucous  membrane  of  the  pharynx,  the  esoph- 
agus, and  the  kirynx,  and  cause  varied  disturbances  in  these 
structures. 

Microscopic  examination  has  shown  that  the  thrush-fungi  ])enetrate 
between  the  cement-rsubstance  of  the  uppermost  layer  of  epitheUal  cells, 
and  then  extend  especially  in  the  middle  layer  of  epithelium,  in  which  they 
cause  atrophy  by  pressure.  At  times  the  fungous  masses  proliferate  down 
to  the  submucosa,  where  they  grow  into  the  blood-vessels  and  the  lymphatics. 
From  this  point  fragmentation  and  embolic  dissemination  into  the  vessels 
of  the  brain  have  been  observed. 

Patients  suffering  from  thrush  complain  principally  of  a  sense 
of  burning  and  pain  in  the  mouth,  while  the  buccal  mucous  mem- 
brane appears  reddened  and  inflamed,  and  the  secretion  of  saliva 
is  increased.     The  saliva  yields  an  acid  reaction,  as  in  most  varie- 


FlG. 


25. — Thrush-fungus  (O'ldium  albicans)  from  the  mouth  of  a  child,  nine  mouths  old 
(personal  observation). 


ties  of  stomatitis,  and  it  may  contain  no  ptyalin.  With  careful 
attention  the  disease  can  be  usually  cured  within  one  or  two  weeks, 
although  in  the  case  of  a  woman  the  duration  was  more  than  one 
and  a  half  years.  As  a  rule,  the  disorder  is  itself  free  from  danger. 
In  newborn  children  thrush  is  attended  with  diarrhea,  which  may 
threaten  life.  This  is  attributed  to  decomposition  by  the  swal- 
lowed thrush-fungi  of  the  ingested  milk  in  the  gastro-intestinal 
tract.  ISIarkod  proliferation  in  the  esophagus  may  render  swal- 
lowing im]i()ssible  in  infants,  with  danger  of  starvation. 

Ktiolog"y. — The  conditions  for  the  development  of  thrush 
are  always  provided  whenever  the  mouth  is  not  kept  sufficiently- 
clean.     The  disease  is,  therefore,  observed  in  the  newborn  and  in 


LEUKOPLAKIA   ORIS  181 

infants  whose  mouths  are  not  freed  from  residua  of  milk  after  each 
meal,  or  whose  mothers  or  nurses  do  not  regularly  cleanse  the 
nipple,  or  who  are  given  inadequately  cleansed  nipples  and  nursing- 
bottles.  In  adults  thrush  develops  in  the  buccal  cavity  in  the 
sequence  of  long-continued  and  debilitating  disease,  such  as  diabetes, 
pulmonary  tuberculosis,  typhoid  fever,  leukemia,  and  carcinoma. 
Thrush-fungi  gain  entrance  into  the  buccal  cavity  in  part  through 
inhalation  from  the  air,  in  which  the  fungi  have  been  demonstrated, 
and  in  part  they  are  conveyed  by  solid  substances  to  which  the 
fungi  have  become  attached.  Thus,  the  thrush-fungi  have  been 
found  upon  both  human  and  artificial  nipples  that  were  not 
properly  cleansed.  It  should,  therefore,  not  occasion  surprise  that 
epidemics  of  thrush  have  been  observed  in  hospitals  and  materni- 
ties, particularly  in  the  past.  Thrush  occurs  with  especial  fre- 
quency in  the  summer  months,  because  heat  favors  the  develop- 
ment of  fungi. 

Treatment. — Prophylactic  and  causal  treatment  furnish  the 
same  indications.  Attention  should  be  directed  to  careful  cleans- 
ing of  the  mouth  and  of  nipples  and  bottles.  In  addition  irriga- 
tion or  rinsing  of  the  mouth  with  borax  may  be  recommended  : 

R   Solution  of  sodium  biborate,  5.0  :  200. 

For  irrigation  of  the  mouth  after  each  meal. 

Grayish-white,  frost-like  deposits  similar  to  those  of  thrush  occur  as 
a  result  of  proliferation  of  sarcince  in  the  mouth  [stomatomycosis  sarcinica), 
although  microscopic  examination  will  under  such  conditions  disclose  square 
fungi  grouped  together  in  fours  side  by  side  and  also  upon  another.  Sar- 
cinse  may  be  readily  confounded  with  the  Micrococcus  tetragenus,  but  it 
should  be  noted  that  with  the  latter  the  fungi  lie  enclosed  in  a  common 
sheath  in  fours. 

LEUKOPLAKIA  ORIS. 

This  disease  leads  to  the  development  of  grayish-white,  yel- 
lowish or  brownish  spots,  which  appear  most  commonly  upon  the 
tongue,  but  may  occur  also  upon  other  portions  of  the  buccal 
mucous  membrane,  and  even  upon  the  uvula,  the  arch  of  the 
palate,  and  the  tonsils.  At  times  a  large  portion  of  the  buccal 
mucous  membrane  is  covered  with  confluent  spots.  These  are 
frequently  raised  above  the  adjacent  surface,  especially  at  the 
margins,  and  at  times  they  appear  cornified.  Microscopic  ex- 
amination discloses  hyperplasia  of  the  epithelial  cells,  with  detach- 
ment and  swelling  in  the  superficial  layers,  flattening  of  the 
papillse,  dilatation  of  the  blood-vessels,  and  accumulation  of  round 
cells  in  the  subepithelial  tissues — in  brief,  signs  of  chronic  inflam- 
mation. 

Among  causative  factors  may  be  mentioned  irritation  of  the 
buccal  mucous  membrane,  such  as  often  occurs  in  heavy  smokers, 
in  alcoholics,  in  consequence  of  carious  teeth,  in  syphilitics,  and 


182  DIGESTIVE  ORGANS 

in  those  with  gastric  disorders.  Men  are  most  commonly  attacked, 
as  may  be  readily  understood  from  the  nature  of  the  causative 
factors.  Often  the  disorder  gives  rise  to  no  symptoms  and  is  dis- 
covered purely  by  accident ;  in  other  instances  complaint  is  made 
of  soreness,  burning,  or  pain  in  the  mouth  and  of  impairment  of 
taste.  Frequently  the  patients  exhibit  a  hypochondriacal  tendency, 
and  are  harassed  by  a  fear  that  they  are  suffering  from  an  incurable 
disease  of  the  stomach  or  from  syphilis. 

The  prognosis,  however,  should  be  cautious,  as  epithelioma 
has  not  rarely  been  observed  to  arise  from  leukoplakia. 

The  treatment  consists,  first,  in  the  removal  of  causative 
influences.  In  cases  of  syphilis  iodin  should  be  administered 
internally  and  applied  topically.  Suiferers  from  gastric  disease 
at  times  obtain  relief,  and  are  even  cured,  by  courses  of  treatment 
at  Carlsbad  or  Yicliy.  Among  medicaments  arsenic  has  been 
employed : 

R   Solution  of  potassium  arsenite, 

Bitter-almond  water,  each,  5.0  (75  minims). — M. 

Dose :  10  drops  thrice  daily  after  meals. 

In  addition  cauterization  with  lactic  acid  or  chromic  acid,  topical 
applications  of  mercuric  chlorid,  argentic  nitrate,  tincture  of 
iodin,  or  papayotin,  and  the  galvanocautery  have  been  recom- 
mended. 

1.  Geographical  tongue  is  the  name  that  has  been  given  to  an  irregu- 
larly shaped  collection  of  often  confluent  red  spots  upon  the  tongue  lying  below 
the  level  of  the  unchanged  adjacent  surface.  Microscopic  examination  dis- 
closes in  these  situations  desquamation  of  the  uppermost  layer  of  epithelial 
cells,  round-cell  accumulation  among  the  remaining  epithelial  cells  and  in 
the  papillary  body,  and  a  coagulated  albuminous  exudate  in  place  of  the 
desquamated  epithelium.  The  disease  either  has  been  unattended  with 
symptoms  or  has  caused  a  sense  of  burning  in  the  mouth.  It  has  proved 
most  obstinate  and  chronic,  although  the  spots  varied  in  shape  from  day  to 
day.  The  disease  attacks  children  most  commonly,  particularly  anemic, 
scrofulous,  and  rachitic  children. 

2.  Black,  hairy  tongue  is  characterized  by  a  blackish  discoloration  of 
the  tongue.  Frequently  the  tongue  presents  also  a  felt-like  roughness  and 
multiple  nodules.  The  condition  is  dependent  especially  upon  hyperkera- 
tosis of  the  epithelial  cells  of  the  filiform  papillse,  the  epithelial  cells  con- 
taining black  and  brownish  pigment-granules.  Such  fungous  formations 
as  may  be  found  are  accidental  contaminations  that  have  nothing  to  do  witli 
the  black  pigmentations.  The  condition,  which  is  often  unattended  with 
symptoms,  or  at  most  gives  rise  to  a  sense  of  burning  in  the  mouth,  occurs 
especially  in  nervous,  debilitated  patients  and  those  suffering  from  gastric 
disorders,  and  it  can  only  be  corrected  by  mechanical  removal  and  cauteriza- 
tion of  the  hyperplastic  epithelial  structures. 

PTYALISM   (SALIVATION), 

Symptoms,  Diagnosis,  and  Prognosis. — Ptyalism  con- 
sists in  increased  secretion  of  saliva,  so  that  either  the  patients  are 
compelled  to  swallow  the  saliva  frequently  or  the  mouth  is  kept 


PTYALISM  183 

open  and  the  saliva  escapes,  and  must  be  received  into  a  pocket- 
handkerchief  or  a  receptacle  of  some  kind.  Often  the  integument 
of  the  chin  is  irritated  by  the  discharge,  and  it  is  actively  red- 
dened, and  slightly  inflamed. 

It  should  be  noted  that  the  escape  of  saliva  is  not  a  result  of  paralysis 
of  sivalloiving  (bulbar  palsy).  Earlier  physicians  designated  this  condition 
false  ptyalism. 

The  collected  saliva  usually  appears  turbid,  as  it  contains  epi- 
thelial cells  and  remnants  of  food.  Occasionally  it  yields  an  acid 
reaction,  and  at  times  potassium  rhodanate  and  ptyalin  are  absent. 
The  patients  suifer  most  from  the  distress  dne  to  efforts  at  swal- 
lowing or  in  consequence  of  disturbed  sleep.  Some  complain  of  a 
drawing  sensation  in  the  region  of  the  parotid  glands,  and  even 
of  increased  warmth  and  tension  in  the  same  situation.  The 
amount  of  urine  may  be  diminished.  In  ptyalism  of  parox- 
ysmal occurrence  I  have  observed  the  amounts  of  urine  and  saliva 
to  vary  reciprocally.  The  duration  of  the  disease  is  variable.  At 
times  ptyalism  is  a  disorder  of  a  few  hours  or  wrecks,  while  at 
other  times  it  may  extend  over  years.  In  cases  of  chronic  ptyal- 
ism progressive  pallor  and  emaciation  develop,  because  the  large 
amounts  of  saliva  swallowed  interfere  with  gastric  digestion. 
Ptyalism  cannot  be  considered  a  disease  directly  dangerous  to  life, 
but  the  likelihood  of  cure  depends  upon  the  curability  of  the 
causative  disorder. 

Ktiology. — Salivation  results  most  frequently  from  reflex  irri- 
tation of  the  salivary  nerves ;  much  less  commonly  there  is  irrita- 
tion of  the  salivary  centers  of  the  cerebrum  or  the  medulla  oblongata, 
as,  for  instance,  in  consequence  of  central  hemorrhage,  softening, 
or  new-growth.  Ptyalism  occurs  also  in  the  insane  and  the  hys- 
terical. The  influence  of  the  cerebrum  upon  the  secretion  of 
saliva  is  recognizable  from  the  fact  that  the  thought  or  the  seeing 
of  food  causes  an  accumulation  of  water  in  the  mouth,  thus  an 
increased  secretion  of  saliva.  In  consequence  of  reflex  irritation 
ptyalism  occurs  in  association  with  most  diseases  of  the  mouth  and 
teeth.  The  irruption  of  the  teeth  also  is  usually  attended  with 
increase  in  the  secretion  of  saliva.  Ptyalism  often  occurs  in  con- 
nection with  diseases  of  the  stomach  and  bowel,  as,  for  instance, 
chronic  gastric  catarrh  and  the  presence  of  tapeworm  in  the 
intestine.  Diseases  of  the  liver,  kidneys,  and  pancreas  also  are  not 
rarely  attended  with  ptyalism.  Frequently  the  reflex  irritation 
emanates  from  the  sexual  organs.  It  is  well  known  that  ptyalism 
not  rarely  occurs  during  pregnancy.  In  some  persons  an  excessive 
secretion  of  saliva  occurs  before  and  during  coitus.  Sensory  irrita- 
tion is  at  times  attended  with  ptyalism,  as,  for  instance,  tickling 
of  the  skin  or  the  hearing  of  shrill  notes.  Occasionally  inflam- 
mation of  the  salivary  glands  themselves  may  be  followed  by 
ptyalism,  but   the    opposite   condition   may  likewise  occur.     At 


184  DIGESTIVE  ORGANS 

times  it  is  impossible  to  elicit  any  cause  for  the  ptyalism,  and 
under  such  circumstances  the  condition  has  been  designated  idio- 
pathic or  pr'unurij  ptyalism. 

Salivation  may  be  excited  intentionally  by  means  of  various  medica- 
ments, particularly  Jaborandi- leaves  and  their  alkaloid,  pilocarpin  hydro- 
chlorate. 

Treatment. — In  order  to  suppress  systematically  an  increased 
secretion  of  saliva  there  is  but  one  trustworthy  remedy,  namely, 
atropin  sulphate,  which  may  be  injected  subcutaneously  or  be 
administered  internally  : 

R     Atropin  sulphate,  0.01  (J^  grain) ; 

Distilled  water,  10.0  (2.}  fluidrams).— M. 

Dose :  From  0.25  to  0.5  (4  to  8  minimsj,  subcutaneously  once  or 
twice  daily. 
Or, 

B:      Atropin  sulphate,  0.005  {-^tj  grain) ; 

Powdered  althea-root,  sufficient  to  make  10  pills. 

Dose :  From  1  to  3  pills  daily. 

In  addition  causal  treatment  should  be  pursued,  and  the  causes  of 
the  salivation  should  be  removed. 

An  uncommon  disease  \»  fibrinous  sialodochitis.  This  alFection  is  attended 
with  the  formation  of  a  fibrinous  exudate  and  of  coagula  in  the  excretory 
ducts  of  a  number  of  salivary  glands,  so  that  the  discharge  of  saliva  is  pre- 
vented, and  a  sense  of  tension  and  swelling  in  the  neighborhood  of  the 
affected  glands  develop.  At  times  the  disease  occurs  paroxysmally.  Cure 
can  be  effected  only  by  mechanical  means,  attempts  being  made  to  expel 
the  coagula  by  pressure. 


II.    DISEASES  OF  THE  PHARYNX  AND  THE  SOFT 

PALATE. 


CATARRH  OF  THE  PHARYNX  AND  THE  SOFT  PAL- 
ATE (CATARRHAL  PHARYNGITIS  AND  ANGINA). 

Ktiology. — Inflammatory  processes  in  the  soft  palate  are 
designated  angina,  because  in  swallowing  a  sense  of  constriction 
is  felt  at  the  site  of  inflammation.  A  distinction  should  be  made 
between  acute  and  chronic  inflammation  of  the  pharipix  and  soft 
palate.  Among  causative  factors,  adjacent  infectious,  chemic, 
thermic,  and  traumatic  (mechanical)  irritation,  stasis,  and  inflamma- 
tion may  be  mentioned. 

lufectious  inflammation  usually  pursues  an  acute  coiwfie,  and  is 
at  times  primary  and  at  other  times  secondary.  When  primary  it 
develops  as  an  independent  infectious  disease,  and  Avhen  secondary 
it  occurs  in  the  sequence  of  other  infectious  diseases,  among  which 


CATARRH  OF  THE  PHARYNX  AND   THE  SOFT  PALATE  185 

may  be  mentioned  scarlet  fever,  measles,  syphilis,  typhoid  fever, 
erysipelas,  and  small-pox.  Primary  infectious  inflammation  of  the 
pharynx  and  the  soft  palate  was  formerly  attributed  to  exposure  to 
cold,  and  it  was  therefore  designated,  rheumatic  (refrigeratory),  but 
at  present  the  tendency  is  correctly  to  believe  that  the  inflammation 
is  not  excited  by  the  cold  alone,  but  that  this,  by  causing  changes 
in  the  circulation,  diminishes  the  resistance  of  the  tissues  to  the 
invasion  of  low  forms  of  organisms,  and  thereby  favors  infection. 
Recent  bacterioloffic  iuvestio:ations  have  shown  that  various  bacteria 
are  capable  of  exciting  inflammation  of  the  soft  palate ;  for  instance, 
the  Streptococcus  pyogenes,  the  Staphylococcus  pyogenes,  the  pneu- 
moniacocci  of  Friinkel,  the  pneumoeocci  of  Friedlander,  and 
others.  Experience  has  shown  that  the  tendency  to  infectious 
angina  is  most  irregularly  distributed.  Anemic,  debilitated,  and 
delicate  persons  as  well  as  rachitic  and  scrofulous  individuals,  are 
attacked  by  infectious  angina  with  especial  frequency.  Chronic 
hypertrophy  of  the  tonsils  likewise  favors  the  development  of  the 
disease.  The  affection  occurs  most  frequently  in  childhood,  and  it 
is  recognized  that  those  who  have  recovered  from  an  attack  of  in- 
fectious angina  often  suffer  several  times  during  the  remainder  of 
life  from  the  same  disease.  Not  rarely  it  occurs  in  epidemic  dis- 
tribution, or  in  institutions  witli  many  inmates  endemics  appear 
from  time  to  time.  Meteorologic  influences  are  of  importance  in 
this  connection,  as  the  disease  occurs  ^\'ith  especial  frequency  and 
is  widely  distributed  with  sudden  changes  in  the  weather. 

The  chemic  irritants  that  give  rise  to  angina  include,  in  addition 
to  actual  caustics  (acids,  alkalies,  mercuric  chlorid,  argentic  nitrate), 
also  indulgence  in  alcohol  and  tobacco.  Alcoholics  and  smokers 
of  tobacco  suffer  mostly  from  chronic  angina  and  pharyngitis, 
because  in  them  the  injurious  influences  are  constantly  operative. 
Certain  medicaments  taken  internally  also  may  give  rise  to  inflam- 
mation of  the  soft  palate  and  the  pharynx,  particularly  potassium 
iodid  and  mercury. 

Among  thermic  irritants  hot  articles  of  food  are  especially  to  be 
mentioned.     Inhalation  of  hot  vapors  occurs  much  less  commonly. 

In  consequence  of  traumatic  or  mechanical  irritation  angina  and 
pharyngitis  occur  with  especial  frequency  in  conjunction  with  in- 
halation of  dust,  and  it  should  therefore  not  excite  surprise  that 
those  engaged  in  certain  occupations  (millers,  furriers,  stonecutters, 
hatmakers,  bakers,  etc.)  frequently  suffer  from  chronic  angina  and 
pharyngitis.  Continued  and  loud  speaking  also  is  capable  of  ex- 
citing the  disease,  and  it  is  therefore  frequently  encountered  in 
speakers,  singers,  actors,  teachers,  officers,  and  w^aiters. 

Hypostatic  catarrh  of  the  soft  palate  and  thepjharynx  usually  pur- 
sues a  chronic  course,  and  occurs  most  commonly  in  the  sequence 
of  chronic  disease  of  the  heart  or  of  the  respiratory  organs. 

Catarrlial  pharyngitis  and  angina  caused  by  extension  from  adja- 


186  DIGESTIVE  ORGANS 

cent  disease  develops  in  conjunction  with  inflammation  of  the  nasal, 

larvngcal,  and  gastric  nmcous  membrane. 

Symptoms,  Anatomic  Alterations,  Diagnosis,  and 
ProgtlOSis. —  i  he  sym})t()ni.s  of  acute  catarrh  of  the  .saft  pa/atc  and 
t/ic  jj/tari/iix  occur  in  purest  form  in  cases  of  primary  infection. 
The  patients  either  are  suddenly  seized  with  fever,  which  may  have 
been  preceded  by  a  chill  or  slight  shivering,  or  general  malaise  and 
languor  may  occur  for  several  liours  or  days  as  prodromes.  The 
fever  may  subside  suddenly  within  twenty-four  hours,  often  Avith 
perspiration,  but  it  not  rarely  persists  for  several  days.  The  pa- 
tients at  times  present  no  other  symptoms,  and  the  affection  may 
be  recognized  accidentally  on  inspection  of  the  oropharyngeal  cav- 
ity, resort  to  which  may  possibly  be  had  because  no  explanation 
for  the  fever  is  ol)vious.  Such  conditions  occur  with  especial  fre- 
quency in  children,  in  whom  so-called  ephemeral  fever  is  often 
nothing  more  than  the  mauifestatiun  of  an  acute  angina.  Labial 
herpes  often  appears.  I  have  also  not  seldom  observed  enlargement 
of  the  spleen. 

As  a  rule,  the  subjective  symptoms  naturally  direct  attention  to 
the  diseased  parts.  The  patients  coniplain  of  severe  pain  in  swal- 
lowing and  in  speaking  at  the  junction  of  the  buccal  and  pharyn- 
geal cavities,  where  also  a  sense  of  constriction  is  appreciable. 
This  is  induced  in  part  by  the  inflammatory  swelling  of  the  dis- 
eased structures,  partly  also  by  the  increased  sensitiveness  of  the 
inflamed  tissues.  The  pain  is  all  the  more  noteworthy  because  the 
patients  are  compelled  to  swallow  frequently  in  consequence  of 
increased  secretion  of  mucus.  Yawning  also  induces  pain,  as  the 
inflamed  tissues  are  stretched  in  consequence  of  this  act.  Often  the 
nasal  speech  is  conspicuous,  and  it  appears  when  the  tonsils  are 
greatly  swollen  and  obstruct  the  nasopharyngeal  space.  Under 
such  circumstances  the  mouth  is  generally  kept  open,  in  order  that 
air  may  enter  the  larynx — mouth-breathing.  The  patients  often 
hold  the  head  stiffly,  and  avoid  rotatory  and  nodding  movements, 
because  pain  in  the  inframaxillary  region  and  in  that  of  the  soft 
palate  is  thereby  induced.  On  palpation  of  the  inframaxillary 
region  painful,  hard,  roundish  structures  are  found  on  one  or  both 
sides  in  the  neigliborhood  of  the  angle  of  the  jaw — inflamed  and 
enlarged  submaxillary  lymphatic  glands — representing  tlie  conse- 
quences of  secondary  infection.  If  the  mouth  be  opened  widely 
and  the  dorsimi  of  the  tongue  is  depressed  with  a  broad,  hard  body 
— for  instance,  the  handle  of  a  firm  spoon — the  changes  in  the 
inflamed  structures  can  be  well  studied,  and  with  greater  accuracy 
than  on  the  cadaver.  These  appear  in  three  forms,  which  may  be 
designated  superficial,  lacunar,  and  parenchymatous  inflammation. 

In  cases  of  superficial  inflammation  the  aft'ected  areas  are  charac- 
terized by  vivid  redness  and  swelling  and  increased  secretion  of 
mucus.     At  times  follicles  of  the  mucous  membrane  appear  as 


CATARRH  OF  THE  PHARYNX  AND   THE  SOFT  PALATE  187 

small,  enlarged,  almost  transparent  nodules,  partly  because  they 
contain  retained  secretion  and  partly  because  inflammatory  cellular 
hyperplasia  has  taken  place  in  them.  In  consequence  of  rupture 
superflcial  follicular  ulcers  may  develop.  Here  and  there,  also, 
superficial  ulceration  of  the  mucous  membrane  may  occur  in 
places  where  the  epithelium  has  been  desquamated.  The  altera- 
tions may  be  confined  to  circumscribed  areas  or  they  may  involve 
the  entire  mucous  membrane  of  the  soft  palate  and  the  pharynx,  sO 
that  a  distinction  must  be  made  between  circumscribed  and  diffuse 
angina  and  pharyngitis. 

Lacunar  angina  is  attended  with  the  formation  of  yellowish  or 
yellowish-gray  deposits  in  the  lacunse  of  the  tonsils,  so  that  the 
latter  are  often  strewn  with  nodules  averaging  about  the  size  of  a 
pin-head.  Often  each  nodule  is  surrounded  by  a  red  hyperemic 
zone.  Not  rarely  the  deposits  extend  gradually  beyond  the  limits 
of  the  individual  lacunse  and  coalesce,  so  that  yellowish  or  grayish- 
green  smeary  deposits  are  visible  upon  the  tonsils  and,  not  rarely, 
also  upon  the  uvula  and  the  arch  of  the  palate.  On  microscopic 
examination  these  are  found  to  consist  of  round  cells,  fat-globules, 
needles  of  fatty  acids,  and  cholesterin-plates,  but  especially  of  bac- 
teria (leptothrix-fi laments,  Streptococcus  pyogenes,  Staphylococcus 
pyogenes,  pneumoniacocci,  etc.).  The  same  anatomic  alterations 
that  occur  in  superficial  and  lacunar  catarrh  occur  also  in  'pharyn- 
geal diphtheria.  The  differential  diagnosis  can  be  made  only  by 
means  of  bacteriologic  examination,  for  in  all  diphtheric  diseases 
diphtheria-bacilli  are  found  in  the  inflammatory  products. 

Parenchymatous  inflammation,  also  designated  phlegmonous 
angina,  is  characterized  by  the  formation  of  a  circumscribed  col- 
lection of  pus,  thus  an  abscess.  It  is  usually  attended  with  intense 
pain.  The  inflamed  area  is  conspicuous  for  its  great  redness  and 
prominence.  The  abscess  often  ruptures  into  the  oropharyngeal 
cavity  in  the  course  of  a  few  days,  w4ien  the  pain  at  once  dimin- 
ishes and  the  swelling  is  reduced  in  size.  Often  the  inflammation 
disappears  in  the  course  of  a  few  days.  Most  frequently  the 
accumulation  of  pus  takes  place  in  the  periglandular  connective 
tissue  about  the  tonsil — so-called  tonsillar  abscess.  Disagreeable 
complications  arise  at  times  in  consequence  of  rupture  of  the 
abscess  and  entrance  of  the  pus  into  the  larynx  during  sleep,  with 
cough  and  danger  of  suffocation  ;  or  in  consequence  of  rupture  of 
the  abscess  externally,  with  dangerous  erosions  of  large  blood- 
vessels in  the  neck,  or  burrowing  downward  of  the  pus,  or  rupture 
through  the  skin  of  the  neck. 

Most  cases  of  acute  angina  and  pharyngitis  terminate  favorably 
within  a  few  days.  Among  complications  may  be  mentioned  albu- 
minuria, which  often  disappears  from  one  day  to  another,  acide 
nephritis,  jjaralysis  of  the  muiicles  of  the  palate,  and  septic  cdtera- 
tions  {multiple,  painful  articular  sicelUng  and  endocarditis).     The 


188  DIGESTIVE  ORGANS 

couviction  has  but  recently  been  arrived  at  that  the  tonsils  fre- 
quently constitute  the  portal  of  entry  for  bacteria  into  the  body, 
even  when  those  structures  themselves  remain  unchancred. 

Chronic  infiammation  of  the  soft  palate  and  the  pharynx  is  unat- 
tended with  fever,  elevation  of  temperature  taking  place  only  when 
acute  exacerbations  occur.  Superficial,  lacunar,  and  parenchyma- 
tous forms  of  chronic  inflammation  also  may  be  distinguished. 

In  superficial  chronic  angina  and  pharyngitis  the  inflamed  parts 
are  notable  for  their  brownish-red  or  grayish-red  color  and  the 
abundant  secretion  of  viscid  mucus.  Frequently  a  number  of  the 
vessels  of  the  mucous  membrane  are  tortuous  and  exhibit  varicose 
dilatation.  Bleeding  may  take  place  from  these  and  give  rise  to 
hemorrhagic  expectoration,  so  that  many  persons  suft'ering  from 
chronic  pharyngitis  believe  themselves  to  be  suffering  from  pul- 
monary tuberculosis.  Owing  to  the  presence  of  abundant  secre- 
tion the  mucous  membrane  frequently  appears  glazed.  At  times 
the  mucus  dries  during  the  night  into  grayish-green  mussel-like 
crusts,  which  in  the  morning  occasion  a  feeling  as  if  a  foreign  body 
were  present,  and  often  can  be  expelled  only  with  difficulty  after 
protracted  hawking  and  struggling.  Often  the  lymph-follicles  of 
the  mucous  membrane  undergo  hypertrophy,  and  also  new  lymph- 
follicles  form,  so  that  the  posterior  wall  of  the  pharynx  especially 
is  strewn  with  small  gray  nodules — granular  pharyngitis.  The 
patients  complain  of  a  feeling  as  from  the  presence  of  a  foreign 
body,  even  of  pain  and  soreness  in  the  pharyngeal  cavity,  while  an 
abundance  of  viscid  mucus  gives  rise  to  increased  frequency  in  the 
act  of  swallowing,  and  often  to  retching  and  nausea.  The  symp- 
toms mentioned  usually  become  apparent  in  speaking  and  singing, 
particularly  also  in  the  morning  if  during  the  night  there  has  been 
opportunity  for  the  mucus  to  collect  and  become  adherent  in  the 
pharyngeal  cavity,  and  it  is  a  common  observation  that  such 
patients  begin  the  day  with  a  rather  protracted  period  of  hawking 
and  retching,  which  subside  only  with  the  completion  of  the  toilet 
of  the  pharynx.  Impairment  of  hearing  and  tinnitus  aurium  occur 
not  rarely  as  complications,  either  because  the  buccal  orifice  of  the 
Eustachian  tube  becomes  occluded  by  swelling  of  the  mucous  mem- 
brane of  the  pharynx  or  because  the  catarrhal  condition  itself  has 
extended  to  the  mucous  membrane  of  the  tube,  and  at  times  even 
to  the  tympanic  cavity.  Although  the  aflection  is  not  a  fatal  one, 
it  is  nevertheless  an  extremely  obstinate  and  troublesome  one,  as 
it  often  renders  the  pursuit  of  the  patient's  occupation  most  diffi- 
cult, and  at  times  even  impossible. 

In  chronic  lacunar  angina,  as  in  the  acute  form,  yellowish  or 
gravish  smeary  masses  accumulate  in  individual  lacunae  of  the 
tonsils,  consisting  princijially  of  bacteria,  and  especially  of  lepto- 
thrix-filamcnts.  ^V.hcn  crushed  these  plugs  emit  a  most  offensive 
odor.     The  patients  complain  principally  of  a  sense  of  tickling. 


CATARRH  OF  THE  PHARYNX  AND   THE  SOFT  PALATE  189 

or  of  the  presence  of  a  foreign  body,  and  from  time  to  time  hawk 
up  the  accumulated  plugs.  At  times  these  undergo  calcification, 
and  form  tonsillar  calculi,  and  are  from  time  to  time  expelled  by 
hawking.  They  may  possibly  be  mistaken  by  the  patient  for 
calcified  tubercles  from  the  lungs.  The  disagreeable  odor  may  be 
a  source  of  distress  to  the  patient. 

Parenchymatous  angina  and  pharyngitis  are  attended  with  in- 
flammatory hypertrophy  of  the  diseased  structures.  If  the  tonsils 
are  involved  in  the  inflammation,  they  may  attain  double  their 
normal  size,  and  they  not  rarely  project  into  the  entrance  of  the 
pharynx  to  such  a  degree  as  to  come  in  contact  in  the  middle  line. 
In  consequence  speech  suffers  and  acquires  a  nasal  character ;  be- 
sides, the  patients  are  consequently  compelled  to  breathe  through 
the  mouth,  and  they  snore  during  sleep.  Finally  the  orifice  of 
the  Eustachian  tube  becomes  obstructed,  and  impairment  of  hear- 
ing and  tinnitus  aurium  result.  It  should  not  be  forgotten  that 
inflamed  and  hypertrophied  tonsils  manifest  a  tendency  to  acute 
inflammation,  and  frequently  are  the  seat  of  acute  recurrent  dis- 
ease. In  some  cases  the  uvula  undergoes  hypertrophy,  and  its 
tip  may  come  to  lie  upon  the  dorsum  of  the  tongue.  The  patients 
then  complain  frequently  of  retching  and  nausea. 

At  times  chronically  inflamed  jjharyngeal  mucous  membrane  presents  a 
pale,  atrophic,  and  attenuated  appearance — chronic  atrophic  pharyngitis. 
Frequently  similar  alterations  are  at  the  same  time  present  upon  the  nasal 
mucous  membrane. 

Of  the  chronic  inflammatory  conditions  of  the  soft  palate  and 
the  pharynx  it  may  be  said  that  none  is  dangerous  to  life,  while 
all  are  distressing  affections,  curable  with  difiiculty,  particularly  as 
they  are  often  dependent  upon  the  occupation  or  upon  bad  habits 
(smoking,  alcohol),  which  the  patients  are  unwilling  to  give  up. 
Not  rarely  chronic  angina  and  pharyngitis  predispose  to  the  occur- 
rence of  chronic  catarrhal  conditions  of  the  nasal,  laryngeal,  tra- 
cheal, and  bronchial  mucous  membrane.  At  times  nervous  com- 
plications also  arise  through  reflex  influences,  as,  for  instance, 
bronchial  asthma,  and  even  epilepsy. 

Treatment. — Patients  suffering  from  acute  angina  and  phar- 
yngitis should  remain  in  bed,  and  partake  only  of  a  liquid  diet, 
preferably  milk,  and  inhale  every  two  or  three  hours  a  solution 
of  potassium  chlorate  through  the  apparatus  of  Siegle.  Gargles 
are  less  worthy  of  recommendation  on  account  of  the  unavoidable 
irritation  of  the  inflamed  structures  : 

R  Potassium  chlorate,  5.0  :  200. 

For  inhalation  (or  gargling)  every  two  or  three  hours. 

If  the  mucous  membrane  is  the  seat  of  severe  pain  and  great 
swelling,  bits  of  ice  may  be  sucked.  The  application  about  the 
neck  of  a  long  rubber  bag  filled  w^ith  ice  may  also  be  recom- 
mended— a  so-called  ice-collar.     If  parenchymatous  inflammation 


190  DIGESTIVE  ORGANS 

is  complicated  by  the  formation  of  an  abscess,  escape  of  the  pus 
externally  must  be  provided  for  by  incision.  Chronic  auf/ina 
and  pharyngitis  demand,  in  the  first  place,  thorough  considera- 
tion of  the  causative  influences,  causal  treatment,  and,  for  instance, 
excessive  indulgence  in  alcohol  and  t()l)acco  must  be  as  rigidly  as 
possible  enjoined,  and  the  patient  should  be  advised  to  avoid  loud 
and  continuous  speaking  and  the  inhalation  of  dust.  Sjrmptom- 
atic  treatment  consists  principally  in  the  local  employment  of 
gargles,  topical  ap])lications,  insufflations,  cauterization,  inhala- 
tions, and  a  sojourn  at  certain  springs.  At  times  surgical  inter- 
vention becomes  necessary.-  For  gargling  solutions  of  potassium 
chlorate,  alum,  sodium  chlorid,  sodium  bicarbonate,  and  ammo- 
nium chlorid  have  been  recommended — all  in  the  proportion  of 
5.0 :  200.  The  therapeutic  agent  must  be  varied  from  time  to 
time,  as  the  mucous  membrane  readily  becomes  accustomed  to 
the  same  remedy,  and  is  then  no  longer  susceptilile  to  its  influ- 
ence. For  topical  application  dilute  tincture  of  iodin  especially 
may  be  recommended,  but  it  is  to  be  Avithheld  if  a  more  acute 
inflammation  results  in  consequence  of  the  application.  Imme- 
diately after  the  application  the  patient  should  gargle  with  water : 

B  Tincture  of  iodin, 

Tincture  of  galls,  each,  5.0  (75  minims). — M. 

Use  daily  as  an  application  with  a  brush. 

Insufflations  are  made  Avith  either  a  glass  tube  or  a  quill,  and 
tannic  acid,  alum,  or  iodoform  may  be  employed  for  the  purpose. 
Caustics  (silver  nitrate,  copper  sulphate,  chromic  acid,  the  gal- 
vanocautery)  are  especially  applicable  to  granular  pharyngitis. 
InJtalations  may  be  practised  with  the  aid  of  Siegle's  apparatus, 
and  the  same  medicaments  are  employed  as  have  been  named  for 
gargling.  Courses  of  treatment  at  springs  often  yield  good  results 
because  the  patient  is  for  a  time  removed  from  the  exciting  causes. 
Especial  repute  in  this  connection  is  enjoyed  by  sulphur-springs 
(Aachen,  Baden,  Heustrich,  Nenndorf,  Schinznach,  Stachelberg, 
Weilbach),  chlorin-springs  (Eras,  Homburg,  Kissingen,  Reichen- 
hall,  Soden,  Wiesbaden),  and  ioclin-springs  (Salzbrunn,  Tcilz, 
Adelheid  Springs).  Hypertrophied  tonsils  and  elongated  uvulas 
should  be  removed  by  surgical  means.  In  order  to  avoid  recur- 
rences of  inflammation  of  the  soft  palate  and  the  pharynx  certain 
prophylactic  measures  should  be  observed.  These  will  vary  in 
accordance  with  the  nature  of  the  exciting  cause,  and  consist  in 
part  in  intelligent  hardening  of  the  body  and  in  part  in  protec- 
tion against  inhalation  of  dust  and  the  like. 

MYCOSIS  PHARYNGIS  LEPTOTHRIOA, 

This  disorder  is  attended  with  the  formation  of  yelloicish  spots, 
often  apparently  cornified,  which  lie  especially  in  the  lacunae  of  the 


CARCINOMA   OF  THE  ESOPHAGUS  191 

tonsils,  and  on  microscopic  examination  are  found  to  consist  prin- 
cipally of  leptothrix-filaments.  The  disease  either  is  unattended 
with  symptoms,  and  is  discovered  accidentally,  or  it  gives  rise  to 
the  feeling  of  a  foreign  body  and  to  efforts  at  retching.  At  times 
the  fungous  granulation  extends  to  the  dorsum  of  the  tongue,  espe- 
cially to  the  circumvallate  papillee,  and  to  the  mucous  membrane 
of  the  larynx  and  even  of  the  trachea.  The  affection,  which  is 
in  itself  free  from  danger,  is  usually  most  obstinate.  At  times 
it  has  been  observed  to  disappear  spontaneously  ;  at  other  times  it 
seems  to  be  dissipated  by  smoking.  In  addition,  gargling  ivith 
mercHi'iG  chlorid  (1.0  :  2000),  and  mechanical,  removal  of  the  deposit 
and  its  destruction  by  means  of  the  galvanocautery ,  have  been 
employed. 


III.   DISEASES   OF  THE   ESOPHAGUS. 


CARONOMA  OF  THE  ESOPHAGUS. 

*  Anatomic  Alterations. — Carcinoma  of  the  esophagus  is 
almost  exclusively  of  primary  origin.  Only  a  few  instances  of 
secondary  carcinoma,  arising  from  dissemination  of  the  germs 
of  the  disease  from  other  organs  previously  the  seat  of  carcinoma, 
are  known.  Most  frequently  carcinoma  of  the  esophagus  is  situ- 
afed  just  above  the  cardia,  but  somewhat  less  commonly  it  devel- 
ops at  the  level  of  the  bifurcation  of  the  trachea,  and  least 
commonly  it  occurs  at  the  beginning  or  in  any  other  portion  of 
the  esophagus.  It  is  rare  for  isolated  carcinomata  to  be  present 
in  several  portions  of  the  esophagus.  The  new-growth  begins  as 
a  small  insular  formation,  and  then  forms  upon  a  more  or  less 
extensive  portion  of  the  mucous  membrane  a  roundish  nodule  pro- 
jecting into  the  lumen  of  the  esophagus.  As  a  rule,  it  is  gradu- 
ally transformed  into  a  girdle-shaped  or  annular  carcinoma,  as  it 
encircles  the  entire  circumference  of  the  esophagus  like  a  ring. 
The  mucous  membrane  in  the  diseased  area  is  thickened  to  the 
extent  of  several  centimeters,  and  consists  here  of  a  whitish, 
medullary,  friable  tissue.  This  may  be  observed  also  in  the 
muscular  layer  of  the  esophagus,  in  which  extension  within  the 
connective-tissue  septa  takes  place.  The  muscular  layer  under- 
goes thickening,  and  even  the  external  surrounding  connective 
tissue. 

Histologically,  carcinoma  of  the  esophagus  is  always  of  the  pavement 
epithelial  variety.  The  morbidly  proliferated,  squamous  epithelial  cells  are 
derived  from  the  epithelial  cells  of  the  mucous  membrane,  but  in  part  also 
from  those  of  the  glands  of  the  mucous  membrane. 


192  DIGESTIVE  ORGANS 

As  may  be  understood,  stenosis  of  the  esophagus  occurs  at  the 
situation  of  the  new-growth.  Above  the  point  of  constriction 
dikitation  of  the  esophagus  takes  place  at  times,  but  by  no  means 
constantly,  while,  below,  the  eso})hagus  may  be  unusually  narrow. 
The  tracheobronchial  glands  adjacent  to  the  esophagus  are  usually 
enlarged  and  the  seat  of  carcinomatous  infiltration.  Less  com- 
monly similar  alterations  are  present  also  in  the  cervical  lymphatic 
glands.  Like  carcinoma  elsewhere,  that  of  the  esophagus  also 
exhibits  a  tendency  to  consfant  r/roirfh  and  to  dmntegration.  The 
first  quality  is  responsible  for  the  fact  that  in  the  course  of  the 
disease  the  constriction  of  the  esophagus  increases,  and  that  at 
times  adjacent  organs  are  compresseil  and  impaired  in  function, 
as,  for  instance,  the  recurrent  laryngeal  nerve.  As  a  result  of 
disintegration  of  the  carcinomatous  tissue  ulceration  takes  place, 
leaving  an  eroded  and  villous,  and  at  times  an  offensively  smell- 
ing, surface.  The  destruction  may  become  so  extensive  that 
scarcely  any  carcinomatous  tissue  is  visible,  and  the  nuiscular 
layer  of  the  esophagus  is  exposed  as  if  dissected  free.  Formerly 
it  was  even  erroneously  supposed  that  the  ulcer  under\\ent  cica- 
trization, and  that  the  carcinoma  was  as  a  result  capable  of  being 
entirely  healed.  The  disintegration  of  the  carcinomatous  tissue 
further  is  attended  with  the  danger  that  adjacent  organs  may  be 
attacked,  and  rupture  of  the  esophagus  take  place  into  them 
(pleura,  lungs,  trachea,  mediastinum,  aorta,  pericardium).  Persons 
dying  of  carcinoma  of  the  esophagus  present  extreme  emaciation, 
brown  atro])hy  of  the  myocardium,  and  almost  emptv  intestines. 

Ktiologfy. — Clinical  observation  has  shown  that  carcinoma  of 
the  esophagus,  like  carcinoma  of  other  organs,  occurs  late  in  life 
(after  the  fortieth  year),  and  in  men  with  twice  the  frequency  that 
it  occurs  in  women.  Immediate  causes  are,  as  a  rule,  not  elicit- 
able,  although  I  have  observed  the  disease  in  numerous  instances 
in  drinkers  and  smokers,  so  that  I  would  ascril)e  some  etiologic 
influence  to  the  irritation  of  the  mucous  membrane  of  the  esoph- 
agus by  alcohol  and  swallowed  tobacco-juice.  Some  patients 
attribute  the  disorder  to  the  entrance  into  the  larynx  of  hot  articles 
of  food  or  foreign  bodies.  In  a  few  instances  carcinoma  has  been 
observed  to  doveloji  from  ulcers  of  the  esojihagus. 

Symptoms. — The  most  constant,  and  frequently  also  the  first, 
symptom  of  carcinoma  of  the  csoj)hagus  consists  in  spontaneously 
developed  and  progressively  increasing  stenosis  of  the  esophagus. 
In  other  instances  other  suspicious  symptoms  have  appeared,  first 
among  which  particularly  pain  and  paralysis  of  the  recurrent 
laryngeal  nerve  are  to  be  mentioned.  I  have  at  times  observed 
pain  to  precede  by  months  the  earliest  difticulty  in  swallowing. 
The  pain  always  remained  confined  to  the  same  situation,  and  was 
at  times  referred  to  the  vertebral  column,  and  at  other  times  behind 
the  sternum.    It  frequently  increased  in  intensity  during  the  night 


CARCINOMA   OF  THE  ESOPHAGUS  193 

and  disturbed  sleep.  No  resistance  was  found  on  introducing  a 
bougie  into  the  esophagus,  but  the  same  point  in  the  esophagus 
remained  constantly  sensitive  on  contact  with  the  instrument. 

Paralysis  of  the  recurrent  laryngeal  nerve  as  a  result  of  carcinoma 
of  the  esophagus  is  due  either  to  pressure  or  to  proliferation  of  the 
new-growth  in  the  trunk  of  the  nerve.  Usually  it  is  the  left 
recurrent  nerve  that  is  affected,  but  less  commonly  both  are  in- 
volved in  the  paralysis.  Unilateral  paralysis  of  the  recurrent 
laryngeal  nerve  can  be  recognized  only  by  laryngoscopic  examina- 
tion (cadaveric  position  of  the  paralyzed  vocal  band,  page  91,  Fig. 
17) ;  when  both  vocal  bands  are  paralyzed  disorders  of  speech,  in 
cough,  and  in  expulsion  are  also  present.  In  some  cases  my  atten- 
tion was  attracted  entirely  by  secondary  carcinoma  in  other  organs 
(liver,  cranium),  and  the  carcinoma  of  the  esophagus  was  over- 
looked because  the  patients  failed  to  complain  of  either  difficulty 
in  swallowing  or  pain  in  the  esophagus. 

Progressive  difficulty  in  swallowing,  in  consequence  of  increasing 
stenosis  of  the  esophagus,  begins  as  a  rule  gradually.  Exceptionally, 
however,  I  have  observed  it  to  set  in  suddenly,  and  further  after 
great  mental  and  physical  exertion  and  strain.  The  patients  gener- 
ally note  at  first  that  customary  boluses  of  food  will  not  pass  beyond 
a  given  point  in  the  esophagus,  but  threaten  to  remain  impacted. 
The  endeavor  is  made  to  avoid  this  circumstance  by  the  swallowing 
of  smaller  boluses,  but  these  after  a  time  also  encounter  obstruction. 
Other  expedients  are  attempted,  such  as  more  thorough  chewing  of 
the  food  and  more  complete  insalivation  of  the  food,  together  with 
rotatory  movements  of  the  head  and  neck,  but  these  also  fail  after 
a  time.  Finally,  the  only  resource  left  is  to  restrict  the  diet  to 
fluids,  because  all  solid  substances  are  regurgitated  in  a  macerated 
state  shortly  after  ingestion,  and  excessive  distention  of  the  esoph- 
agus with  solid  material  gives  rise,  by  pressure  partly  upon  the 
trachea  and  partly  upon  the  adjacent  vagus,  to  shortness  of  breath, 
a  sense  of  anxiety,  and  palpitation  of  the  heart.  The  ingestion  of 
liquids,  also,  is  attended  with  increased  resistance,  and  thus  the 
patient  passes  gradually  into  a  state  in  which  no  food  can  be  intro- 
duced into  the  stomach  and  the  bowel  through  the  mouth,  and 
death  from  starvation  cannot  be  long  deferred.  It  is  distinctive  of 
the  food  regurgitated  that,  in  contradistinction  from  the  acid  con- 
tents of  the  stomach,  it  yields  a  neutral  reaction  and  not  rarely 
has  a  fetid  odor.  Amylacea  are  partially  transformed  into  sugar 
in  the  esophagus  by  the  saliva,  and  the  patients  therefore  often 
state  that  the  regurgitated  matters  possess  a  sweetish  taste.  Further, 
repeated  variations  in  the  degree  of  stenosis  of  the  esophagus  occur 
in  the  course  of  the  disease,  partly  because  portions  of  the  new- 
growth  are  broken  off,  and  the  lumen  of  the  eso])hagus  is  thus 
increased,  partly  because  at  times  ingested  materials  become  im- 
pacted above  the  constriction. 

13 


194  DIGESTIVE  ORGANS 

The  patients  uiulorgo  progressive  emaciation,  and  tlie  skin 
acquires  a  grayish-yellow  or  earthy  hue  and  a  leathery  and 
wrinkled  aj)pearance.  Owing  to  their  asthenia  the  patients  are 
compelled  to  remain  in  bed,  and  f"re(piently  on  assuming  the  erect 
posture  they  suffer,  in  consequence  of  cerebral  anemia,  from 
tinnitus  aurium,  obscurity  of  vision,  palpitation  of  the  heart,  and 
syncope.  At  times  delirium  due  to  inanition  occurs.  The  abdo- 
men is  generally  scaphoid  on  account  of  the  empty  state  of  the 
intestines,  and  tlie  bowels  are  obstinately  constipated.  The  urine 
is  voided  in  small  amounts  and  contains  much  indican.  The 
bodily  temperature  is  often  subnormal.  Progressive  apathy  sets 
in,  and  finally  gradual  dissolution  takes  place.  The  duration 
of  the  disease  is  usually  more  than  six  and  less  than  twenty- 
four  months.  Naturally,  when  carcinoma  of  the  esophagus  is 
suspected  investigation  for  ol)jective  evidence  of  the  presence  of 
stenosis  of  the  esophagus  should  never  be  omitted,  and  the  only 
certain  way  of  doing  this  consists  in  the  introduction  of  a  bougie 
into  the  esophagus. 

The  most  serviceable  bougies  are  the  Enf/lish  red  bougies  with  lateral 
fenestra.  If  it  be  desired  to  determine  the  degree  of  stenosis,  bougies  of 
varying  size  should  be  employed.  It  is  important  to  examine  microscopic- 
ally with  care  the  substances  caught  in  the  fenestra,  as  these  sometimes 
consist  of  carcinomatous  tissue,  considei'ation  being  given  especially  to  the 
abundant  presence  of  ])avement  epithelial  cells,  with  numerous  nuclei,  and 
to  spherical  laminated  epithelial  cells  (carcinoma-nests  or  carcinoma-pearls). 
If  these  structures  be  not  found,  the  examination  with  the  bougie  will  dis- 
close only  the  presence  of  stenosis  of  the  esophagus,  and  the  carcinomatous 
character  of  the  affection  must  be  determined  from  other  circumstances. 
In  order  to  learn  the  seat  of  the  disease  the  simplest  method  consists  in 
applying  the  bougie  externally  alone  the  mouth  aud  the  vertebral  column, 
and  noting  the  position  of  the  tip  of  the  instrument.  The  observation  can  be 
made  more  precisely  by  measuring  the  bougie  with  a  centimeter-measure 
and  comparing  the  result  with  the  average  measurements  of  the  esophagus. 
The  following  are  the  dimensions  of  the  esophofjus : 

Entire  length  of  the  esophagus,  2o  cm.  (9.8  inches). 

The  distance  from  the  edge  of  the  teeth  to  the  beginning  of  the  esoph- 
agus, 15  cm.  (5.9  inches). 

Length  of  the  cervical  portion  of  the  esophagus,  5  cm.  (1.9  inches). 

Length  of  the  dorsal  portion,  17  cm.  (G.7  inches). 

Length  of  the  abdominal  portion,  3  cm.  (1.2  inches). 

The  point  of  intersection  between  the  esophagus  and  the  left  bronchus 
cross  is : 

From  the  beginning  of  the  esophagus,  8  cm.  (3.1  inches). 

From  the  edge  of  the  teeth,  15  —  8  =  23  cm.  (9  inches). 

Should  a  bougie  not  be  at  hand,  tentative  observations  should  be  made 
by  auscultation  of  the  esophagus.  The  stethosco]ie  is  applied  along  the  left 
side  of  the  vertebral  column  from  the  seventh  cervical  to  the  eleventh 
dorsal  vertebra.  If  the  ])atient  swallows  water  when  directed,  there  is 
heard  in  healthy  persons  throughout  the  entire  course  of  the  esophagus  a 
peculiar  sound  like  that  which  every  one  may  hear  when  the  ears  are  closed 
with  the  fingers  and  the  act  of  swallowing  is  practised.  In  persons  suftering 
from  stenosis  of  the  esophagus  this  swallowing  sound  is  audible  only  down 
to  the  point  of  constriction,  while  below  this  it  is  wanting.  The  stoallowing 
sounds  of  the  stomach  also  are  altered  in  the  presence  of  constriction  of  the 


CARCINOMA   OF  THE  ESOPHAGUS  195 

esophagus.  In  order  to  detect  these  the  stethoscope  is  placed  in  the  angle 
between  the  ensiform  cartilage  and  the  left  costal  margin  while  water  is 
swallowed.  In  healthy  persons  two  murmurs  will  be  audible  in  from  five 
to  ten  seconds,  the  first  of  which  is  designated  the  injection-sound  and  the 
second  the  expression-sound.  These  sounds  are  explained  by  the  fact  that 
the  ingested  fluid  is  usually  forced  through  the  esophagus  into  the  stomach 
by  the  contraction  of  the  muscles  of  the  oropharyngeal  cavity,  and  that 
then  the  remainder  is  forced  into  the  stomach  by  contraction  of  the  muscu- 
lature of  the  esophagus.  When  the  esophagus  is  constricted  the  injection- 
sound  occurs  after  an  unusually  long  interval,  and  often  appears  gurgling 
and  prolonged,  while  the  second  sound  is  often  wanting.  For  the  detection 
of  alterations  in  the  esophagus,  examination  with  mirrors — esophagoscopy 
— has  been  proposed,  but  this  has  not  yet  received  general  application,  prin- 
cijially  because  the  instruments  thus  far  constructed  are  not  sufficiently 
mauipulable  on  the  part  of  both  physician  and  patient. 

Carcinoma  of  the  esophagus  is  not  rarely  attended  with  com- 
IjlicaUons,  which  may  give  rise  to  serious  consequences.  Paral- 
ysis of  the  recurrent  laryngeal  nerve  has  already  been  considered. 
Bilateral  recurrent  paralysis  renders  easily  possible  the  entrance 
of  foreign  bodies  into  the  air-passages,  with  the  development  of 
aspiration-pneumonia,  abscess,  and  gangrene  of  the  lungs.  Similar 
alterations  in  the  lungs  occur  not  rarely  also  Avithout  recurrent 
paralysis,  because  in  the  act  of  regurgitation  individual  masses 
of  food  readily  enter  the  larynx  and  the  deeper  air-passages.  In 
some  instances  I  have  observed  symptoms  of  paralysis  of  the 
sympathetic  nerve  (contracted  pupils,  narrowing  of  the  palpebral 
fissure,  recession  of  the  eyeball).  Occasionally  serious  hemor- 
rhage takes  place,  at  times  soon  after  the  introduction  of  a  bougie 
into  the  esophagus,  and  at  other  times  spontaneously.  In  the 
latter  event  the  bleeding  may  be  due  to  disintegration  of  carcino- 
matous tissue  and  perforation  of  blood-vessels,  or  to  erosion  of 
adjacent  large  blood-vessels,  as,  for  instance,  the  aorta.  Under 
such  circumstances  death  may  take  place  rapidly  from  hemor- 
rhage. Often  rupture  of  the  esophagus  into  adjacent  organs  takes 
place,  most  frequently  into  the  left  bronchus.  The  patients  are 
then  seized  with  severe  cough  after  the  ingestion  of  food,  and 
expectorate  portions  thereof.  Further,  aspiration-pneumonia  and 
abscess  and  gangrene  of  the  lung  soon  develop,  because  a  portion 
of  the  food  enters  the  deeper  air-passages.  In  other  instances 
rupture  takes  place  into  the  larynx,  directly  into  the  lungs,  into 
the  pleural  cavity,  or  into  the  mediastinum.  If  air  enters  the 
mediastinal  connective  tissue  from  the  esophagus,  it  generally 
extends  upward  beneath  the  connective  tissue  of  the  jugular 
fossa,  with  the  development  of  subcutaneous  emphysema  (projec- 
tion of  the  skin,  crepitation  on  manipulation).  I  have  frequently 
observed  rupture  of  the  esophagus  preceded  for  several  days  by 
inexplicable  febrile  movement.  At  times  carcinoma  of  the  esoph- 
agus extends  to  the  vertebral  column,  destroying  the  vertebrae, 
and  giving  rise  to  spinal  pressure-paralysis.     The  complications 


196  DIGESTIVE  OliGANS 

include  further  secondary  or  metastatic  carcinoma  in  other  organs, 
as,  for  instance,  in  the  liver,  and  these  may  dominate  the  clinical 
picture  to  such  a  degree  that  the  primary  growth  in  the  esophagus 
will  be  overlooked. 

Diagnosis. — The  diagnosis  of  carcinoma  of  the  esophagus 
is  usually  indirect.  In  a  person  at  a  susceptible  age  constriction 
of  the  esophagus  is  found,  and  its  carcinomatous  nature  is  decided 
upon  because  of  its  develoj)ment  without  demonstrable  cause,  its 
gradual  increase,  its  advance  Avith  progressive  asthenia,  and  its 
continuance  without  appreciable  alteration  in  organs  contiguous 
to  the  esophagus.  It  is  rare  that  portions  of  the  new-growth 
are  caught  in  the  fenestra  of  the  bougie  that  on  microscopic  ex- 
amination can  be  definitely  recognized  as  carcinomatous,  or  that 
portions  of  the  growth  are  found  in  the  regurgitated  matters. 
Especial  care  should  be  taken  to  determine  that  the  stenosis  of 
the  esophagus  is  not  dug  to  an  aneurysm  of  the  aorta,  and  in  no 
instance  should  a  bougie  be  introduced  into  the  esophagus  until 
aneurysm  of  the  aorta  has  been  excluded  by  the  absence  of  ab- 
normal duluess,  vascular  murmurs,  and  alteration  in  pulse.  If 
this  precaution  be  neglected,  it  may  happen  that  an  aneurysm  of 
the  aorta  compressing  the  esophagus  may  be  perforated  by  the 
tip  of  the  bougie,  and  death  result  rapidly  from  hemorrhage. 

With  regard  to  othe?'  varieties  of  stenosis  of  the  esophagus  a  few  remarks 
of  etiologic  significance  may  be  apjjropriate  at  this  jjlace.  The  symptoms 
and  the  treatment  agree  essentially  with  those  of  the  stenosis  due  to  carci- 
noma. In  accordance  with  the  seat  of  the  constriction  a  distinction  is  made 
between  intra-esophageal,  parietal,  and  extra-esophagcat  stawsis  of  the  esopjh- 
agtis.  Intra-esophageal  stenosis  may  be  due  to  the  lodgment  of  articUs  of 
food  and  foreign  bodies  and  proliferated  thrush-masses.  Parietal  stenosU<  of 
the  esophagus  may  result  from  cicatrices  in  the  sequence  of  burns,  corrosion, 
tuberculous,  diphtheric,  peptic,  and  syphilitic  ulcers,  and  variola.  It  occurs 
in  association  with  nev-groirths  (carcinoma,  polyps,  gummatous  nodules) 
and  abscesses.  Pulsion-diverticula  Avhen  filled  give  rise  to  constriction  of 
the  esophagus.  Among  other  causes  for  constriction  of  the  esophagus  that 
have  been  mentioned  are  congenital  stenosis,  hypertrophg,  and  spas7n  of  the 
rmisculatiire  of  the  esophagus.  Extra-esophageal  stenosis  may  also  be  desig- 
nated compression-stenosis  of  the  esophagus.  The  following  examples  may  be 
mentioned :  Aneurysm  of  the  aorta,  pericarditis,  pleurisy,  ne\v-growths  of 
the  lung,  the  mediastinum,  the  pleura,  the  pericardium,  the  vertebral  col- 
umn, the  thyroid  gland  (struma),  ossification  and  thickening  of  the  cricoid 
cartilage,  burrowing  abscesses  of  the  vertebral  column,  luxation  of  the 
hyoid  bone. 

Prognosis. — The  prognosis  of  carcinoma  of  the  esophagus, 
as  of  carcinoma  elsewhere,  is  unfavorable,  and  a  fatal  issue  is 
unavoidable. 

Treatment. — Internal  remedies  for  the  cure  of  carcinoma 
are  not  known,  and  the  only  reliable  method  of  treatment  con- 
sists in  removal  of  the  growth  with  the  knife.  As  a  matter  of  fact, 
resection  of  the  carcinomatous  portion  of  the  esophagus  has  been 
attempted,  but  the  operation   naturally   can   only   be   undertaken 


DIVERTICULA    OF  THE  ESOPHAGUS  197 

when  the  carcinoma  is  sitnated  in  the  cervical  portion  of  the 
esophagus  and  is  thus  accessible  to  the  knife — and  this  is  un- 
common. In  the  majority  of  cases  symptomatic  treatment  alone  is 
possible,  and  the  indications  are  by  means  of  nutritious  food  to 
maintain  the  strength  and  to  prolong  life  as  well  as  possible, 
and  to  preserve  the  permeability  of  the  esophagus.  The  most 
suitable  diet  consists  in  liquids  and  soft  food.  Among  these  may 
be  mentioned  milk  with  somatose,  broths,  milk  with  tea,  milk 
with  chocolate,  milk  with  cocoa,  eggs,  wine,  beer,  rice,  oatmeal- 
gruel  prepared  with  milk,  beef-tea,  scraped  ham  or  tenderloin,  tender 
meat-sausage,  and  chopped  meat.  Food  should  be  taken  every 
hour,  but  slowly  and  not  too  much  at  a  time.  In  order  to  main- 
tain the  patulousness  of  the  esophagus  for  as  long  a  time  as  pos- 
sible systematic  employment  of  the  bougie  should  be  practised  daily 
or  at  intervals  of  several  days  in  accordance  with  existing  con- 
ditions. Even  if  the  sound  cannot  be  passed  through  the  con- 
stricted portion  of  the  esophagus,  deglutition  will  be  rendered 
materially  easier  or  again  possible.  Attempts  have  been  made  to 
introduce  permanent  catheters  through  the  constricted  portion  of 
the  esophagus  and  permit  them  to  remain,  but  objection  has  been 
raised  to  this  procedure  from  various  sources  that  it  favors  disin- 
tegration of  the  tumor.  If  the  stricture  of  the  esophagus  has 
become  impassable,  two  methods  only  remain  of  introducing  food 
into  the  body — either  gastrostomy  or  nutrient  enemata.  Ga,stros- 
tomy  has  heretofore  not  been  attended  with  brilliant  results,  per- 
haps because  it  has  generally  been  undertaken  too  late  ;  nor  can 
life  be  prolonged  for  any  considerable  length  of  time  by  means 
of  nutrieait  enemata,  because  it  is  impossible  to  secure  absorption 
of  a  sufficient  amount  of  nutrient  material  from  the  mucous  mem- 
brane of  the  large  intestine. 

The  following  formula  may  be  recommended  as  a  nutrient  enema : 
150  c.c.  of  lukewarm  milk,  150  c.c.  of  lukewarm,  slightly  salted  meat-broth, 
two  eggs,  3  teaspoonfuls  of  somatose,  2  tablespoonfuls  of  starch-flour,  1  tea- 
spoonful  of  sugar,  and  10  drops  of  tincture  of  opium.  By  means  of  a  Hegar 
funnel  a  mixture  of  this  sort  at  the  temperature  of  the  body  is  permitted  to  flow 
into  the  rectum  thrice  daily — in  the  morning  three  hours  after  having  evacu- 
ated the  contents  of  the  rectum  by  means  of  cold  water.  Great  difficulty 
arises  from  the  circumstance  that  the  patients,  by  reason  of  their  weakness, 
are  unable  to  retain  the  enemata,  or  that,  in  spite  of  all  care,  the  mucous 
membrane  of  the  rectum  soon  becomes  irritable,  and  in  consequence  reten- 
tion of  the  enemata  is  impossible. 

DIVERTICULA  OF  THE  ESOPHAGUS, 

A  diverticulum  of  the  esophagus  consists  in  cii-cumscribed 
dilatation  of  this  tube.  A  distinction  is  made  between  pulsion- 
diverticula  and  traction-diverticida,  accordingly  as  the  dilating 
force  is  applied  from  within  outward  or  traction  is  exercised 
from  without. 


198  DIGESTIVE  ORGANS 

Pulsion-diverticula  arc  almost  always  situated  at  the  jnnetion 
of  the  pharynx  w  itli  the  esophagus,  and  are  rather  a  part  of"  tiie 
former.  Most  commonly  they  arise  in  the  middle  line,  bulging 
outward  from  this  situation  in  one  or  both  directions.  Under 
such  conditions  they  may  attain  the  size  of  a  child's  head.  On 
anatomic  examination  they  are  frecfuently  found  to  be  unsupplied 
with  a  muscular  layer,  so  that  it  has  been  correctly  assumed  that 
the  tendency  to  the  development  of  a  pulsion-diverticulum  is  con- 
genital, and  is  attributable  to  deficient  development  of  the  muscular 
layer,  and  therefore  to  diminished  resistance  on  the  part  of  the 
wall  of  the  esophagus.  Other  observers  are  of  the  opinion  that 
pulsion-diverticula  result  from  incomplete  internal  cervical  fistulse 
in  the  region  of  the  first  branchial  cleft.  Persons  with  pulsion- 
diverticula  of  the  esophagus  frequently  state  that,  after  eating, 
a  swelling  forms  on  the  left  side  of  the  neck,  which  gradually 
increases  in  size  with  the  further  ingestion  of  food.  Pressure  and 
manipulation  may  cause  disappearance  of  the  swelling,  ^vhile  the 
patients  are  conscious  of  the  entrance  of  food  into  the  esophagus. 
At  the  same  time  loud  gurgling  murmurs  are  not  rarely  generated. 
The  diverticulum  has  a  tendency  to  intercept  swallowed  articles 
of  food,  and  during  the  process  of  eating  to  have  its  orifice 
directed  more  and  more  into  the  lumen  of  the  esophagus.  Often 
regurgitation  of  the  food  takes  place  some  time  after  its  ingestion. 
The  ejected  matters  appear  macerated,  and  often  emit  a  fetid  odor. 
On  introducing  a  bougie  into  the  esophagus  it  will  be  observed  that 
at  times  the  instrument  passes  readily  into  the  esophagus,  while 
at  other  times  it  is  obstructed  if  its  extremity  enters  the  divertic- 
ulum. It  may  also  happen  that  if  two  bougies  are  introduced 
into  the  esophagus  the  one  will  enter  the  diverticulum,  while  the 
other  passes  into  the  stomach  without  obstruction.  By  distention 
with  the  aid  of  a  teaspoonful  each  of  sodium  bicarbonate  and  tartaric 
acid,  given  separately  in  a  wineglassful  of  water,  it  may  be  pos- 
sible to  induce  a  prominence  in  the  neck,  which  on  percussion 
yields  a  tympanitic  note.  A  pulsion-diverticulum  is  attended  with 
the  danger  of  progressive  emaciation  and  of  sfarration,  for  in  addi- 
tion to  the  interception  of  food  a  distended  pulsion-diverticulum, 
by  projecting  into  the  esophagus,  prevents  the  passage  of  food  to 
the  stomach.  Pulsion-diverticula  have  recently  been  excised  suc- 
cessfully ;  otherw^ise  the  only  remedy  would  consist  in  systematic 
nutrition  by  means  of  the  stomach-tube.  Pulsion-diverticula  occur 
mo,'it  comuionlji  in  men.  The  earliest  symptoms  usually  do  not 
appear  until  the  fortieth  year  of  life,  and  they  are  often  attributed 
to  swallowed  foreign  bodies,  injuries  of  the  cervical  region,  and 
constrictina:  articles  of  clothins:.  Ossification  and  thickening  of 
the  cricoid  cartilage  occurring  late  in  life  appear  also  to  be  of 
causative  influence. 

Traction- diverticula  of  tlie  esophagus  are  not  recognizable  during 


DILATATION  OF  THE  ESOPHAGUS.  199 

life  on  account  of  their  smallness.  They  are  most  frequently  situ- 
ated at  the  level  of  the  bifurcation  of  the  trachea,  for  they  are 
principally  dependent  upon  inflammatory  alterations  in  the  tracheo- 
bronchial lymph-glands.  In  consequence  of  periadenitis  adhe- 
sions readily  form  between  the  lymphatic  glands  and  the  esophagus, 
and  if  subsequently  contraction  and  diminution  in  size  take  place 
in  the  inflamed  lymphatic  glands  the  wall  of  the  esophagus  is 
drawn  outward  in  the  form  of  a  small,  acute  funnel.  Often  the 
glandular  structure  will  be  visible  at  the  apex  of  the  funnel  as  a 
dark  body.  The  danger  from  traction-diverticula  resides  in  their 
tendency  to  rupture,  aiKl  this  may  occur  spontaneously  or  be  caused 
by  incarcerated,  hard  particles  of  food.  Rupture  may  take  place 
into  the  air-passages,  when  the  entrance  of  food  gives  rise,  in 
addition  to  distressing  irritative  cough,  also  to  inflammation,  sup- 
puration, and  gangrene  of  the  lungs ;  or  into  the  mediastinal  con- 
nective tissue,  where  it  gives  rise  to  putrefaction  or  to  accumulation 
of  air,  or  to  both  ;  or  into  the  pleura,  the  pericardium,  or  the  aorta, 
with  the  development  respectively  of  pleurisy  or  pericarditis,  or 
the  occurrence  of  death  from  hemorrhage  within  a  short  time. 

DILATATION  OF  THE  ESOPHAGUS, 

Dilatation  of  the  entire  esophagus  may  be  congenital  or  acquired, 
and  in  the  latter  event  some  of  the  causes  mentioned  include  fre- 
quent vomiting,  excessive  ingestion  of  hot  water,  impaction  of 
hot  food,  chronic  catarrh  of  the  esophagus,  a  blow  upon  the  chest, 
and  the  carrying  of  heavy  weights.  The  dilatation  of  the  esoph- 
agus is  at  times  spindle-shaped  and  at  other  times  more  uniform. 
In  the  first  instance,  the  greatest  degree  of  dilatation  usually  cor- 
responds with  the  mid-dorsal  region.  The  dilated  esophagus  is  at 
times  capable  of  enclosing  a  man's  arm,  but  it  is  also  considerably 
increased  in  length,  and  at  times  makes  numerous  lateral  turns  in 
its  course.  Dilatation  of  the  esophagus  may  be  recognized  from 
the  fact  that  considerable  lateral  movement  can  be  made  with  a 
sound  that  has  been  introduced.  If,  on  the  other  hand,  the  esoph- 
agus makes  lateral  turns,  the  introduction  of  the  bougie  may  be 
attended  with  considerable  difficulty.  Under  such  conditions  the 
patients  also  complain  of, difficulty  in  swallowing  and  often  regur- 
gitate ingested  matter,  and  they  may  slowly  undergo  great  emaci- 
ation and  die  in  consequence  of  inanition.  Experience  has  shown 
that  difficulty  in  swallowing  generally  does  not  occur  until  after 
the  twentieth  year  of  life. 

Partial  congenital  dilatation  of  the  esophagus  constitutes  the 
so-called  ante-stomach,  which  consists  in  a  dilatation  of  the  ]3or- 
tion  of  the  esophagus  that  is  situated  below  the  diaphragm.  The 
condition  is  without  significance,  and  has  nothing  to  do  with  rumi- 
nation, as  was  formerly  supposed. 


200  DIGESTIVE  ORGANS 

Secondary  dilatation  of  the  esophagus  takes  place  above  con- 
strictions of  the  esophagus,  but  it  is  by  no  means  a  necessary 
consequence  of  such  conditions.  The  dilatation  becomes  the 
ijreater  the  o;reater  the  amoimt  of  food  ing;ested  and  the  lony-er  it 
remains  above  the  constriction. 

CATARRHAL  ESOPHAGITIS, 

Ktiology. — Catarrh  of  the  esophagus  is  of  only  subordinate 
clinical  importance.  It  develops,  like  catarrhal  conditions  of 
otlu'r  mucous  membranes,  in  consequence  of  the  action  of  mecliaiii- 
cal  (hard  articles  of  food,  swallowed  foreign  bodies,  careless  intro- 
duction of  the  sound),  toxic  (the  swallowing  of  acids,  alkalies,  and 
other  corrosive  substances),  and  thermic  irritants  (hot  articles  of 
food,  abuse  of  alcohol  and  of  tobacco).  Infectious  influences  prob- 
ably play  a  part  in  the  inflammatory  processes  that  develop  in  the 
course  of  certain  infectious  diseases  (small-pox,  measles,  scarlet 
fever,  typhoid  fever,  erysipelas).  At  times  inflammation  of  the 
mucous  membrane  of  the  esophagus  arises  by  extension  from  catar- 
rhal conditions  of  the  stomach,  the  pharynx,  the  larynx,  the  bron- 
chi, from  mediastinitis,  pericarditis,  and  pleurisy.  A  special 
variety  is  constituted  by  the  hifpostatie  catarrh  that  is  observed  in 
connection  with  chronic  cardiac  and  respiratory  diseases.  In 
accordance  with  the  course  of  the  disease  a  distinction  has  been 
made  between  acute  and  chronic,  and,  in  accordance  with  its  dis- 
tribution, between  diffuse  and  circumscribed  catarrh  of  the  esoph- 
agus. 

Anatomic  Alterations. — Acute  catarrh  of  the  esophagus  is 
characterized  less  bv  unusual  eno;oro;ement  with  blood  and  redness 
of  the  mucous  membrane,  than  by  marked  detachment  and  des- 
quamation of  the  epithelium.  The  follicles  of  the  mucous  mem- 
brane, in  consequence  of  accumulation  of  secretion,  often  appear 
as  small,  clear  and  transparent  nodules,  which  not  rarely  are 
arranged  upon  the  summit  of  the  folds  of  mucous  membrane  like 
strings  of  pearls.  If  follicles  rupture,  superficial  follicular  ulcers 
result.  In  addition,  if  excessive  desquamation  of  epithelial  cells 
takes  place  epithelial  ulcers  form. 

Chronic  catarrh  of  the  esopJiagus  is  attended  with  brownish- 
red  discoloration  of  the  mucous  membrane  and  thickening  of  the 
epithelium.  The  muscular  layer,  also,  may  undergo  inflammatory 
tiiickeuing.  At  times  dilatation  of  th(>  esophagus  takes  place. 
The  abundant  formation  and  accumulation  of  mucus  further  con- 
stitute a  striking  feature. 

Symptoms,  Diagnosis,  and  Prognosis. — The  morbid 
manifestations  are  in  part  indefinite  in  character,  including  deep- 
seated  pain  in  the  course  of  the  vertebral  column,  or  between  the 
scapulae,  pain  in  swallowing — odynphagia,  at   times  dificulty  in 


PEPTIC  ULCER   OF  THE  ESOPHAGUS  201 

swallowing,  and  even  regurgitation.  In  cases  of  acute  catarrh  it 
has  frequently  been  observed  that  phigs  of  desquamated  epithelial 
cells  from  the  mucous  membrane  were  ejected.  The  introduction 
of  a  bougie  into  the  esophagus  should  if  possible  be  avoided,  in 
order  that  no  irritation  be  excited.  It  is  noteworthy  that  an 
abundance  of  mucus,  at  times  blood-tinged,  frequently  adheres  to 
the  sound.  The  duration  of  the  disease  and  the  prognosis  depend 
upon  the  fact  whether  the  cause  can  be  removed  or  not. 

Treatment. — In  cases  of  acute  catarrh  of  the  esophagus  only 
cool  liquid  nourishment  should  be  permitted.  If  severe  pain  be 
present,  bits  of  ice  may  be  sucked  and  subcutaneous  injections  of 
morphin  given.  Chronic  catarrh  of  the  esophagus  has  been  treated 
by  means  of  astringent  ointments  (argentic  nitrate,  0.5 — 7|  grains  ; 
wool-fat  and  lard,  each,  5.0 — 75  grains),  which  are  applied  by 
means  of  a  sponge-bougie.  It  is  important  to  direct  attention  to 
causal  treatment  (withdrawal  of  alcohol  and  tobacco). 


PHLEGMONOUS   ESOPHAGITIS. 

Phlegmonous  esophagitis  is  attended  with  suppuration  in  the 
submucosa  of  the  esophagus.  The  purulent  infiltration  may  also 
extend  to  the  muscular  layer.  The  pus  often  ruptures  through 
several  openings  into  the  lumen  of  the  esophagus.  The  disease  is 
difficult  of  recognition.  The  most  important  manifestation  con- 
sists in  sudden  disappearance  of  the  signs  of  constriction  of  the 
esophagus  after  regurgitation  of  the  pus.  jS'aturally  the  possibility 
will  always  be  present  that  an  abscess  in  the  neighborhood  of  the 
esophagus — for  instance,  a  burrowing  abscess  of  the  vertebral 
column — has  ruptured  into  the  esophagus. 

Among  the  causes  of  this  uncommon  disorder  are  impacted 
foreign  bodies,  intense  corrosion,  infectious  diseases,  extension  of 
inflammatory  processes  (phlegmonous  pharyngitis,  phlegmonous 
gastritis),  and  suppuration  in  the  neighborhood  of  the  esophagus. 
At  times  it  is  not  possible  to  elicit  any  cause. 

The  treatment  is  purely  symptomatic. 


PEPTIC  ULCER  OF  THE  ESOPHAGUS. 

Peptic  or  round  ulcer  of  the  esophagus  is  a  rare  disorder.  The 
ulcer  is  situated  near  the  cardia,  where  it  develops  in  consequence 
of  digestion  of  the  mucous  membrane  in  places  by  active  gastric 
juice  left  with  food  after  the  act  of  vomiting.  The  ulcer  is 
usually  round,  with  sharp  margins.  It  is  scarcely  recognizable 
during  life.  Its  dangers  consist  in  hemorrhage,  perforation,  cica- 
trization with  stenosis  of  the  esophagus,  and  carcinomatous  degen- 
eration. 


202  DIGESTIVE  ORGANS 

SPONTANEOUS  RUPTURE  OF  THE  ESOPHAGUS. 

A  few  instances  are  on  record  in  ^\•lnch  ruptnre  of  the  esoph- 
agus has  taken  ph\ce  in  the  midst  of  perfect  health,  at  times  after 
preceding  efforts  at  vomiting  or  expulsion,  with  the  occurrence  of 
death  within  a  short  time.  The  jjatients  were  usually  men  ad- 
dicted to  excessive  indulgence  in  alcohol,  and  probably  the  wall 
of  the  esophagus  had  been  previously  softened.  As  a  rule,  a  longi- 
tudinal tear  up  to  five  centimeters  was  present,  beginning  at  the 
cardia  and  extending  to  the  lower  extremity  of  the  thoracic  por- 
tion of  the  esophagus  ;  less  commonly  two  longitudinal  tears  were 
present  or  a  single  circular  tear.  As  a  result  the  contents  of  the 
stomach  had  entered  the  mediastinum,  and  hence  the  pleural 
cavity,  and  the  surface  of  the  lung  was  brownish  and  softened. 
The  patients,  as  a  rule,  have  cried  out  at  the  onset  of  the  accident 
that  something  had  ruptured  within  their  body,  and  have  com- 
plained of  agonizing  pain  in  the  course  of  the  vertebral  colunm, 
with  a  sense  of  annihilation  and  a  fear  of  death,  with  coldness  and 
pallor  of  the  skin  and  an  imperceptible  pulse.  Signs  of  pneumo- 
thorax and  of  subcutaneous  emphysema  appeared,  because  air 
passed  from  the  esophagus  into  the  pleural  cavity  and  into  the 
mediastinal  connective  tissue,  and  thence  into  the  subcutaneous 
connective  tissue.  There  Mere  also  nausea,  retching,  and  inability 
to  swallow.  Death  usually  resulted  within  twenty-four  hours,  with 
increasing  asthenia. 

The  prognosis  is  unfavorable. 

The  treatment  consists  in  subcutaneous  injections  of  morphin 
and  camphor  in  order  to  relieve  the  pain  and  sustain  the  strength. 

SOFTENING  OF  THE  ESOPHAGUS  (ESOPHAGO- 
MALACIA). 

Softening  of  the  esophagus  takes  place  especially  in  patients  in 
Avhom  the  agonal  period  is  protracted  (tuberculous  meningitis,  dis- 
eases of  the  brain).  The  wall  of  the  esophagus  is  swollen  and  so 
friable  that  it  tears  on  the  slightest  manipulation.  Often  it  is 
found  perforated  in  the  dead  subject,  and  the  contents  of  the 
stomach  have  escaped  into  the  abdominal  or  the  pleural  cavity. 
In  accordance  with  the  color  of  the  softened  tissue,  a  distinction  is 
made  between  gray,  white,  and  brown  softening.  White  and  gray 
softening  have  probably  developed  only  after  death,  from  the 
entrance  of  the  contents  of  the  stomach  into  the  esophagus,  with 
digestion  of  its  wall.  Brown  softening  may  also  have  occurred 
during  the  agonal  period,  with  failure  of  the  circulation,  when  the 
acid  gastric  juice  is  no  longer  neutrali/ed  by  the  circulating  blood 
and  thereby  rendered  innocuous.  The  condition  can  scarcely  be 
diagnosed  during  life. 


PARALYSIS  OF  THE  ESOPHAGUS  20-3 

THRUSH  OF  THE  ESOPHAGUS  (OESOPHAGOMYCOSIS 

OIDICA), 

Thrush  of  the  esophagus  probably  occurs  always  in  association 
with  thrush  of  the  oropharyngeal  cavity,  and  is  attended  with  the 
presence  upon  the  mucous  membrane  of  the  esophagus  of  yellowish 
or  grayish-yellow  deposits,  in  which  on  microscopic  examination 
the  readily  recognized  thrush-fungus,  Oidium  albicans  (page  180, 
Fig.  25),  can  be  found.  The  deposits,  which  usually  develop  abun- 
dantly in  the  upper  and  lower  portions  of  the  esophagus  particu- 
larly, and  do  not  extend  to  the  mucous  membrane  of  the  stomach, 
are  at  times  punctate,  at  other  times  striate,  and  occasionally 
they  assume  the  form  of  hollow  or  solid  casts  of  the  esophagus. 
As  a  result  they  may  give  rise  to  difficulty  in  swallowing.  At 
times,  also,  plugs  of  thrush-fungi  have  been  ejected.  The  mucous 
membrane  of  the  esophagus  is  unchanged,  or  beneath  the  thrush- 
deposit  there  may  be  observed  hyperemia,  rarely  loss  of  tissue, 
purulent  infiltration  of  the  submucosa,  penetration  of  the  fungi 
into  the  blood-vessels,  and  embolic  dissemination  to  the  brain, 
together  with  corresponding  cerebral  manifestations.  The  aifec- 
tion  develops  usually  in  association  with  thrush  of  the  mouth  in 
debilitated  individuals  who  neglect  to  keep  the  buccal  cavity  clean, 
and  particularly  in  children  with  diarrhea  and  in  patients  suffering 
from  pulmonary  tuberculosis,  carcinoma,  and  diabetes.  Should 
difficulty  in  swallowing  arise,  emetics  may  be  administered  for  the 
purpose  of  removing  the  thrush-masses  mechanically.  Under 
some  conditions  introduction  of  the  sound  will  be  necessary.  In 
addition,  the  internal  employment  of  borax  may  be  recommended  : 

R     Solution  of  sodium  biborate,  5.0  :  200. 

Dose :  from  5  to  15  c.c.  (from  1  teaspoonful  to  1  table- 
spoonful)  every  two  hours. 

PARALYSIS  OF  THE  ESOPHAGUS. 

Paralysis  of  the  esophagus  occurs  in  association  with  disease 
of  the  brain  and  the  cervical  cord  (hemorrhage,  abscess,  softening, 
new-growth,  echinococcus,  tabes  dorsalis,  multiple  cerebrospinal 
sclerosis,  progressive  paralysis  of  the  insane,  bulbar  paralysis). 
At  times  it  occurs  in  conjunction  with  hysteria.  It  has  also  been 
observed  in  consequence  of  pressure  on  the  cervical  vagus  by  en- 
larged lymphatic  glands.  The  cases  in  which  the  disorder  develops 
in  the  sequence  of  diphtheria,  syphilis,  alcoholism,  lead-poisoning, 
and  mercurial  poisoning  are  probably  attributable  to  neuritic  alter- 
ations. At  times  the  affection  has  appeared  after  exposure  to  cold, 
the  ingestion  of  hot  food,  and  psychic  distu7'bances.  The  disorder 
is  characterized  by  difficulty  in  sivalloiving — paralytic  dysphagia. 
Especial  difficulty  usually  attends  the  swallowing  of  fluids  and  of 


204  DIGESTIVE  ORGANS 

small  particles  of  food.  The  act  of  swallowing  is  often  attended 
with  a  p'ecidiar  gurgling  sound — dysphagia  sonora.  If  the  patients 
are  careless  in  the  ingestion  of  food,  over-distention  of  the  esoph- 
agus therewith  may  give  rise  to  a  sense  of  fear,  danger  of  suffoca- 
tion, and  2^f(^p^f'^if^on  of  the  heart.  A  sound  introduced  into  the 
esophagus  can  be  moved  to  and  fro  with  undue  readiness  and  free- 
dom. The  prognosis  depends  upon  whetlier  the  causative  condi- 
tions can  be  removed  or  not.  Nourishment  should  be  introduced 
by  means  of  a  tube,  the  paralyzed  musculature  should  be  stimu- 
lated daily  by  means  of  a  suitable  sound-electrode  connected  with 
a  faradic  current  of  not  too  great  strength  and  introduced  into  the 
esophagus,  and  the  fundamental  disorder  should  be  attacked,  as,  for 
instance,  syphilis  with  mercury  and  iodin,  diphtheria  with  injec- 
tions of  strychnin,  lead-poisoning  with  potassium  iodid. 

SPASM  OF  THE  ESOPHAGUS  (ESOPHAGISM) , 

Spasm  of  the  musculature  of  the  esophagus  is  observed  in  some 
central  neuroses  (chorea,  epilepsy,  tetanus,  hydrophobia,  hysteria, 
hypochondriasis).  The  disorder  may  also  occur  in  association  with 
anatomic  diseases  of  the  central  nervous  system.  At  times  it  is 
induced  by  local  irritation  of  the  esophagus  (introduction  of  the 
sound,  hard  articles  of  food).  Those  cases  in  which  the  condition 
arises  after  the  employment  of  belladonna,  stramonium,  or  spoiled 
meat  may  be  considered  as  instances  of  a  toxic  variety.  Esoph- 
agism  occurs  through  reflex  influences  in  association  with  enlarge- 
ment of  the  tonsils,  chronic  pharyngeal  catarrh,  chronic  esophagitis, 
carcinoma  of  the  esophagus  and  of  the  stomach,  the  presence  of 
worms  in  the  intestine,  and  diseases  of  the  sexual  organs.  Occa- 
sionally it  occurs  as  a  result  of  emotional  disturbances,  as,  for 
instance,  in  persons  ^^■ho  incorrectly  believe  that  they  have  been 
bitten  by  a  rabid  dog.  The  principal  symptom  consists  in  dijfi- 
culty  in  surdloicing — spastic  dysphagia.  Liquids  can  be  better 
swallowed  than  solids.  The  act  of  deglutition  is  attended  with  a 
disagreeable  sense  of  constriction  internally,  which  at  times  sets  in 
in  the  presence  or  the  tli ought  of  food.  The  introduction  of  a 
sound  is  attended  with  resistance,  or  the  instrument  is  suddenly 
grasped  spasmodically  and  cannot  be  pushed  onward.  A  dis- 
tinctive feature  is  the  fact  that  if  the  sound  is  permitted  to  remain 
quietly  the  spasm  frequently  relaxes,  and  the  passage  of  the  in- 
strument into  the  stomach  can  take  place  without  obstruction. 
The  condition  may  occur  parox3'sraally  or  continuously,  and,  in 
accordance  wnth  the  causative  condition,  it  may  persist  for  hours, 
days,  or  months.  Should  the  nutritive  disturbance  become  pro- 
found, nourishment  must  be  administered  by  means  of  the  tube 
or  of  nidrient  enemcda.  In  addition  narcotics  (subcutaneous  injec- 
tions of  morphin)  and  local  galvanization  with  currents  of  not  too 


DISEASES  OF  THE  STOMACH  205 

great  strength  may  be  employed.     Of  particular  importance  is  the 
treatment  of  the  primary  disorder. 


IV.   DISEASES   OF  THE  STOMACH. 


PRELIMINARY  CONSIDERATIONS, 

Until  within  a  few  years  it  was  considered  sufficient  to  apply 
also  to  the  study  of  the  diseases  of  the  stomach  the  physical 
methods  of  examination  alone  of  inspection,  palpation,  percussion, 
and  auscultation.  However  valuable  the  diagnostic  results  yielded 
even  yet  by  these  methods,  they  still  leave  the  investigator  com- 
pletely in  the  dark  as  to  the  functions  of  the  stomach,  and  the 
fact  is  therefore  to  be  welcomed  that  within  recent  times  a  study 
of  the  functions  of  the  stomach  has  been  added  to  the  physical 
methods  of  examination.  Three  conditions  especially  must  be 
taken  into  consideration,  namely,  the  absorptive  power  of  the 
stomach,  the  motor  activity  of  the  stomach,  and  the  constitution 
of  the  gastric  juice. 

1.  To  determine  the  absorptive  power  of  the  stomach  a  small 
gelatin-capsule,  containing  0.2  (3  grains)  of.  potassium  iodid,  is 
employed.  This  is  swallowed  by  the  patient  in  the  morning  when 
the  stomach  is  empty,  and  the  saliva  is  then  examined  every  five 
minutes  for  the  presence  of  iodin.  For  this  purpose  starch-paper 
(bibulous  paper  that  has  been  dipped  in  a  paste  of  starch  and 
water  and  then  dried  in  the  air)  and  fuming  nitric  acid  are  used. 
By  touching  the  mucous  membrane  of  the  cheek  the  paper  is 
moistened  with  saliva,  and  then,  by  means  of  a  glass  rod,  a  drop 
of  fuming  nitric  acid  is  applied  to  the  moistened  spot.  If  iodin 
has  been  absorbed  and  has  made  its  appearance  in  the  saliva,  the 
starch-paper  is  stained  reddish  or  bluish  at  the  exposed  spot.  In 
performing  this  test  care  should  be  taken  that  the  gelatin-capsule 
is  wholly  swallowed  and  is  not  possibly  crushed  in  the  mouth,  in 
order  that  the  potassium  iodid  be  not  admixed  with  the  saliva 
already  in  the  mouth.  It  is  absolutely  necessary  that  the  test  be 
made  when  the  stomach  is  empty,  because,  after  food  has  been  taken, 
the  absorptive  activity  of  the  stomach  is  exceedingly  variable,  even 
in  healthy  persons.  In  a  healthy  person  ten  or  fifteen  minutes 
will  elapse  before  the  first  traces  of  iodin  can  be  demonstrated  in 
the  saliva.  In  the  presence  of  disease  of  the  stomach  there  is  fre- 
quently a  prolongation  of  the  period  of  absorption.  This  period 
is  prolonged  with  especial  regularity  in  cases  of  carcinoma  of  the 
stomach,  not  rarely  for  more  than  sixty  minutes.  The  same  con- 
dition may,  however,  be  present  also  in  cases  of  acute  and  chronic 


206  DIGESTIVE  ORGANS 

gastric  catarrh,  gastric  ulcer,  and  gastric  dilatation.  The  absorp- 
tive activity  of  the  stomach  is  impaired,  further,  in  anemic, 
cachectic,  and  febrile  states. 

Little  is  known  with  regard  to  acceleration  of  gastric  absorption.  It  ia 
believed  to  have  been  observed  in  cases  of  recent  ulcer  of  the  stomach, 
without  cicatrization. 

2.  The  motor  activity  of  the  stomach  is  studied  l^y  having  the 
patient  take  a  test-meal,  and  determining  after  an  interval  of  six 
hours,  with  the  aid  of  a  soft  tube  introduced  into  the  stomach, 
whether  remains  of  the  food  are  still  present  or  not.  If  the  motor 
activity  of  the  stomach  is  unimpaired,  the  viscus  will  have  pro- 
pelled its  contents  into  the  intestine  within  six  hours.  A  test-meal 
consists  of  a  plate  of  soup  made  with  water  or  with  ilour,  a  tender 
beefsteak  with  an  eg^,  and  a  wheat  roll.  An  ordinary  rubber  gas- 
tube  may  be  employed  as  a  stomach-tube,  the  sharp  edges  being 
cut  away  with  the  aid  of  scissors,  or  a  soft  stomach-tube  with 
lateral  fenestra,  which  is  virtually  nothing  more  than  an  unusually 
long  and  thick  Xelaton  catheter.  Both  varieties  of  tube  can 
be  readily  introduced  into  the  stomach  with  swallowing  move- 
ments. In  order  to  obtain  the  gastric  contents  the  expression- 
method  may  be  employed.  After  the  tube  has  been  introduced 
into  the  stomach  down  to  the  lower  curvature  the  patient  begins 
to  make  active  expulsive  efforts.  If  the  stomach  contains  chyme, 
this  M'ill  be  expelled,  and  it  can  be  received  into  a  vessel  held 
beneath  the  free  opening  of  the  tube.  Should  unexpectedly  nothing 
appear,  a  glass  funnel  must  be  introduced  into  the  free  opening 
of  the  stomach-tube,  and  through  this  lukewarm  water  should 
be  introduced  into  the  stomach.  As  soon  as  the  flow  ceases  the 
introduction  is  suspended,  the  tube  is  pinched  between  the  fingers, 
the  glass  funnel  is  inverted  into  a  suitable  vessel,  and  the  pressure 
of  the  fingers  is  released,  when  the  water  and  the  gastric  contents 
will  escape.  Diminution  in  the  motor  activity  of  the  stomach  may  be 
recognized  from  the  fiict  that  the  viscus  still  contains  considerable 
amounts  six  hours  after  the  ingestion  of  food.  The  condition 
occurs  especially  in  association  with  carcinoma,  dilatation,  and 
atony  of  the  stomach,  but  it  may  also  attend  other  diseases  of  the 
stomach,  as,  for  instance,  gastric  catarrh. 

Little  is  known  with  regard  to  morbid  increase  in  the  motor  activity  of  the 
stomach,  although  a  number  of  observations  are  on  record  in  which  the 
stomach  was  empty  two  hours  after  the  ingestion  of  food,  and  the  patient 
constantly  complained  of  hunger.  It  should  further  be  noted  whether  the 
gastric  contents  obtained  exhibit  evidence  of  insufficient  mastication  of 
the  food — a  common  fault  and  a  frequent  cause  of  diseases  of  the  stomach 
of  varied  kind. 

3.  The  digestive  power  of  the  gastric  juice  depends  upon  the 
fact  whether  free  hydrochloric  acid,  pepsin,  and  lab-ferment  are 
present,  and  attention  should  be  directed  to  all  of  these  in  cases 


DISEASES  OF  THE  STOMACH  207 

of  disease  of  the  stomach.  In  order  to  obtain  gastric  juice  for 
examination  a  test-meal  or  a  test-breakfast  is  given.  A  test-meal 
may  be  constituted  of  the  ingredients  previously  named,  viz., 
a  plate  of  soup  made  with  water  or  with  flour,  a  tender  beef- 
steak with  an  egg,  and  a  wheat  roll.  The  test-breakfast  consists 
of  a  large  cup  (250  c.c.)  of  tea  without  sugar  and  of  a  wheat  roll 
(35  gm.).  The  gastric  contents  are  obtained  by  expression  with 
the  aid  of  a  soft  stomach-tube  four  hours  after,  and  a  test-meal 
one  hour  after,  a  test-breakfast.  The  periods  named  have  been 
shown  by  experience  to  be  the  most  favorable  for  the  examina- 
tion. Personally,  I  prefer  the  test-breakfast  to  the  test-meal, 
because  the  manipulations  are  cleaner  and  the  examination  can 
be  more  quickly  terminated  without  aifecting  its  reliability.  The 
contents  of  the  stomach  obtained  are  naturally  not  pure  gastric 
juice,  but  chyme  mixed  therewith ;  experience  has,  however, 
shown  that  under  normal  conditions  this  somewhat  dilute  gastric 
juice  possesses  quite  definite  and  constant  properties. 

In  the  first  place,  the  materials  obtained  are  carefully  inspected 
with  the  unaided  eye  for  the  presence  of  foreign  admixture  (blood, 
mucus,  shreds  of  tissue),  and  with  regard  to  the  condition  of  the 
food  ingested.  Then  the  reaction  of  the  gastric  juice  is  tested 
by  means  of  litmus-jmper.  This  will  be  found  almost  unexcep- 
tionally  acid,  so  tliat  blue  litmus-paper  is  stained  red.  The  pres- 
ence of  an  acid  reaction  by  no  means  indicates  that  the  gastric 
contents  contain  free  acid,  for  it  may  be  due  also  to  acid  salts  in 
solution,  especially  phosphates.  Next,  Congo  paper  (bibulous 
paper  stained  with  a  solution  of  Congo  red)  is  used  to  determine 
whether  the  gastric  contents  contain  free  acid.  In  this  event  the 
Congo  paper  is  stained  blue.  The  Congo  reaction  yields  no  in- 
formation as  to  the  nature  of  the  free  acid,  and  whether  it  be  due 
to  hydrochloric  acid  or  to  organic  acids  (acetic,  lactic,  butyric). 

To  demonstrate  the  presence  of  free  hydrochloric  acid  the 
'phloroglucin-vanilUn  solution  of  Giinzburg  (phloroglucin,  2.0 ;  va- 
nillin, 1.0;  alcohol,  30.0)  is  employed.  Of  this  reagent  about  5 
drops  are  placed  upon  a  porcelain  dish,  and  an  equal  amount  of 
filtered  gastric  contents  is  added.  The  mixture  is  then  carefully 
heated  over  a  flame  until  dried.  If  the  gastric  juice  contain  free 
hydrochloric  acid,  a  beautiful  carmine-red  color  appears  on  evapo- 
ration. Complete  investigation  of  tlie  ga.stric  juice  requires 
further  also  quantitative  determination  of  the  hydrochloric  acid. 
It  is  necessary  to  understand  that  two  kinds  of  hydrochloric 
acid  must  be  distinguished  in  the  gastric  contents,  the  combined 
and  the  free  hydrochloric  acid.  The  proteids  of  the  gastric  con- 
tents immediately  enter  into  combination  with  a  portion  of  the 
hydrochloric  acid  of  the  gastric  juice,  and  only  when  tliis  combi- 
nation has  been  completely  saturated  does  hydrochloric  acid 
remain  uncombined,  therefore,  as  free  hydrochloric  acid.     In  the 


208  DIGESTIVE  ORGANS 

further  digestion  of  proteids  this  free  hydrochloric  acid  only  is 
of  ijnportance,  and  this  fact  will  explain  why  attention  has  been 
directed  especially,  and  often  even  exclusively,  to  the  free  hydro- 
chloric acid.  Experience  has  shown  that  in  a  healthy  person 
after  ingestion  of  the  test-meal  previously  mentioned  the  pro- 
portion of  free  hydrochloric  acid  in  the  gastric  juice  is  from  0.15 
to  0.25  per  cent. 

The  cheraic  methods  for  determining  the  total  hydrochloric 
acid,  the  combined  and  the  free  hydrochloric  acid  in  the  gas- 
tric juice,  are  too  complicated  for  the  general  practitioner,  apart 
from  the  fact  that  they  cannot  even  be  considered  as  accurate, 
and  often  it  will  suffice  for  the  physician  to  estimate  the  total 
acidity  of  the  gastric  juice,  which  can  be  done  without  much 
trouble  or  the  consumption  of  much  time.  In  doing  this  not 
only  the  hydrochloric  acid  must  be  considered,  but  everything  in 
solution  in  the  gastric  contents  that  yields  an  acid  reaction,  as,  for 
instance,  phosphates,  and  under  some  conditions  lactic  and  acetic 
and  butyric  acids.  To  determine  the  total  acidity  of  the  gastric 
contents  a  1  :  10  normal  sodium-hydroxid  solution  is  employed,  of 
which  1  c.c.  neutralizes  0.00365  gm.  of  hydrochloric  acid.  The 
test  is  made  in  the  following  manner :  10  c.c.  of  filtered  gastric 
contents  are  introduced  into  a  glass  by  means  of  a  pipet,  and  5 
drops  of  an  alcoholic  solution  of  phenolphthalein  are  added.  The 
gastric  contents  remain  unchanged ;  at  most  a  slight  and  entirely 
insignificant  cloudiness  forms.  From  a  graduated  buret  normal 
sodium-hydroxid  solution  is  permitted  to  drop  until  a  coloration 
appears,  and  persists  in  spite  of  constant  shaking.  By  this  means 
evidence  is  furnished  that  the  first  drop  of  normal  sodium-hydroxid 
solution  is  in  excess,  and  that  all  of  the  acid  of  the  gastric  con- 
tents is  neutralized,  for  a  phenolphthalein  solution  that  remains 
colorless  in  an  acid  solution  at  once  assumes  a  red  hue  with  the 
slightest  excess  of  alkali.     The  estimation  is  made  as  follows  : 

If  4  c.c.  of  normal  sodium-hydroxid  solution  are  employed, 
1  "  sodium  hydroxid  =  0.00365  of  hydrochloric  acid, 
4   "  "  '"  =0.01460  '"  "  and 

10   "        gastric  contents  contain  0.0146       "  "  and 

100   "  "  "  "        0.146         "  "  =  0.146  per  cent. 

If,  continuing  the  illustration,  4  c.c.  of  sodium-hydroxid  solu- 
tion have  been  required  to  neutralize  10  c.c.  of  gastric  contents, 
and  therefore  40  c.c.  of  sodium  hydroxid  to  neutralize  100  c.c. 
of  gastric  contents,  the  total  acidity  of  the  gastric  juice  is  for 
brevity's  sake  designated  simply  as  40.  The  gastric  contents  of  a 
healthy  individual  should  have  a  total  acidity  of  from  30  to  60. 
If  the  total  acidity  be  less  than  30,  the  condition  is  designated 
hypacidity,  and  if  more  than  60,  hyperacidity. 

Hypacidity  is  inconceivable  without  deficiency  of  free  hydro- 
chloric acid  in  the  gastric  juice,  so  that  the  demonstration  of  total 


DISEASES  OF  THE  STOMACH  209 

hypaoidity  indicates  also  hypochlorhydria.  Hyperacidity  of  the 
gastric  juice  can,  however,  be  induced  also  by  increase  in  the 
organic  acids.  Under  such  circumstances  the  free  hydrochloric 
acid  and  the  organic  acids  must  be  determined  quantitatively. 
For  this  purpose  the  filtered  gastric  contents  are  shaken  vigor- 
ously with  an  equal  amount  of  ether  in  a  separatory  funnel,  and 
the  gastric  contents  are  then  poured  back  into  a  glass  vessel. 
The  ether  will  take  up  the  organic  acids.  Then  normal  sodium- 
hydroxid  solution  is  added  to  10  c.c.  of  gastric  contents  until  the 
first  drop  of  gastric  contents  heated  upon  a  porcelain  dish  with  a 
drop  of  phloroglucin-vanillin  solution  no  longer  yields  a  red  color. 
In  this  way  demonstration  would  be  aiforded  that  all  free  hydro- 
chloric acid  has  been  neutralized  by  the  normal  sodium-hydroxid 
solution.  The  amount  of  hydrochloric  acid  can  be  readily  esti- 
mated from  the  amount  of  sodium-hydroxid  solution  employed. 

If  it  be  further  desired  to  estimate  the  amount  of  organic  acids,  it  would 
be  necessary  to  evaporate  the  ether,  to  dissolve  the  residue  in  water,  and 
to  determine  the  acidity  of  the  aqueous  solution  by  means  of  normal  sodium 
hydroxid  and  phenolphthalein  in  the  manner  previously  described.  Organic 
acids  are  generated  in  the  stomach  by  the  fermentation  of  carbohydrates. 
Lactic  acid  is  almost  constantly  present  in  the  gastric  contents.  It  can  be 
readily  demonstrated  with  the  aid  of  Uffelmann's  reagent  (solution  of  ferric 
chlorid,  1  drop;  carbolic  acid,  0.4;  distilled  water,  30.0).  If  filtered  gastric 
juice  be  added  to  Uffelmann's  reagent,  a  canary -yellow  color  appears  in  the 
amethyst-blue  solution  in  the  presence  of  lactic  acid.  Hydrochloric,  acetic, 
and  butyric  acids  likewise  induce  discoloration,  but  the  color  is  smoky  gray 
and  not  yellow.  For  the  recognition  of  acetic  and  butyric  acids  dependence 
will  generally  be  placed  upon  the  sense  of  smell.  A  penetrating  sour  odor 
is  indicative  of  the  presence  of  acetic  acid,  and  a  rancid  odor  of  that  of 
butyric  acid. 

The  determination  of  the  hydrochloric  acid  in  the  gastric  juice 
is  naturally  of  great  significance  in  treatment.  Originally  it  was 
thought  that  the  knowledge  was  of  great  diagnostic  importance, 
but  this  has  not  been  confirmed  by  more  extensive  experience. 
Anachlorhydria  occurs  frequently,  but  not  constantly,  in  associa- 
tion with  carcinoma  of  the  stomach.  It  is  also  observed  in  con- 
nection with  acute  and  chronic  gastric  catarrh,  extensive  cicatri- 
zation of  the  gastric  mucous  membrane  after  the  action  of  corrosive 
agents,  amyloid  degeneration  of  the  gastric  mucous  membrane, 
and  anemic,  cachectic,  and  febrile  states.  Hyperchlorhydria  has 
been  observed  in  connection  with  round  ulcer  of  the  stomach,  and 
it  also  occurs  as  an  independent  gastric  neurosis. 

Among  organic  acids  the  abundant  and  persistent  appearance  of  lactic 
acid  has  erroneously  been  given  diagnostic  significance  with  regard  to  the 
presence  of  carcinoma  of  the  stomach.  Organic  acids  may  be  abundantly 
present  in  connection  with  all  fermentative  processes  of  the  gastric  con- 
tents, and  with  especial  constancy  with  gastric  dilatation. 

Pepsin  occurs  almost  always  in  sufficient  amount  in  the  gastric 
juice.    It  is  only  wanting,  together  with  hydrochloric  acid,  when  the 

14 


210  DIGESTIVE  ORGANS 

glmuls  of  the  gastric  mucous  nicnibranc  luivc  undcrgono  atrophy — 
so-called  gastric  anadcnia.  In  order  to  form  an  opinion  as  to  the 
sufficiency  of  the  pepsin  in  the  gastric  contents  the  so-called  Jour- 
(/lasH  test  is  made.  Into  each  of  four  test-tubes  are  introduced 
5  c.c.  of  filtered  gastric  contents.  The  first  tube  is  left  unchanged, 
to  the  second  are  added  0.5  of  })epsin,  to  the  third  2  drops  of  dilute 
hydrochloric  acid,  and  to  the  fourth  0.5  of  pepsin  and  2  drops  of 
dilute  hydrochloric  acid.  Then  a  disc  of  albumin  of  uniform  size, 
best  obtained  by  means  of  a  cork-cutter,  or  flakes  of  fibrin  of 
equal  amount,  are  introduced  into  each  tube.  The  fibrin  should  be 
thoroughly  washed  and  freed  from  blood,  and  it  can  then  be  ke])t  in 
glycerin.  The  four  tubes  are  placed  in  the  thermostat  at  the  tem- 
perature of  the  body,  and  the  digestive  process  during  the  suc- 
ceeding hours  is  observed.  If  satisfactory  digestion  takes  place 
in  the  first  tube,  the  result  indicates  that  the  gastric  juice  contains 
sufficient  free  hydrochloric  acid  and  pepsin.  If  digestion  takes 
place  in  the  second  test-tube  and  not  in  the  first,  this  indicates 
a  deficiency  of  pepsin  ;  if  in  the  third  test-tube  and  not  in  the  first 
or  second,  a  deficiency  of  hydrochloric  acid ;  and  if  only  in  the 
fourth  tube,  a  deficiency  of  both  pepsin  and  hydrochloric  acid. 

The  gastric  juice  almost  always  contains  lah-ferment  also  in  suf- 
ficient amount.  This  is  absent  only  in  gastric  adenia.  To  demon- 
strate its  presence,  to  10  c.c.  of  unboiled  milk  5  drops  of  filtered 
gastric  contents  are  added,  and  the  mixture  is  jilaced  in  a  thermo- 
stat at  the  temperature  of  the  body.  The  presence  of  lab-ferment 
is  indicated  by  the  occurrence  of  coagulation  in  the  milk  within 
from  fifteen  to  thirty  minutes. 

ACUTE  GASTRIC  CATARRH. 

Ktiology. — Acute  gastric  catarrh  is  an  exceedingly  common 
disorder,  and  in  the  majority  of  cases  it  is  dependent  upon  errors 
in  diet.  These  may  at  times  consist  in  the  ingestion  of  too  full 
a  meal,  at  other  times  in  the  ingestion  of  food  that  is  too  hot  or 
too  cold  or  insufficiently  masticated,  and  therefore  generally  eaten 
too  hastily,  and  at  still  other  times  finally  in  the  ingestion  of 
spoiled  food  or  drink.  Infants  are  frequently  attacked  by  acute 
gastric  catarrh,  l)ecause  milk  is  readily  decom])osed  and  frequently 
■contains  fermentative  bacteria.  All  other  causative  factors  are 
much  less  commonly  effi'ctive.  Gastric  catarrh  is,  however,  most 
likely  to  be  of  toxic  origin,  less  commonly  from  the  ingestion  of 
chemic  poisons  than  from  indulgence  in  alcohol  in  too  great  con- 
centration or  in  too  great  amount.  Traumatic  gastric  catarrh, 
resulting  from  injury  in  the  epigastrium,  and  rheumatic  or  refrige- 
ratorii  gastric  catarrh,  resulting  from  the  local  or  general  influence 
of  cold,  are  of  rare  occurrence.  Acute  infectious  and  debilitating 
diseases  generally  are  more  frequently  accompanied  by  acute  gastric 


ACUTE  GASTRIC  CATARRH  211 

catarrh.  Gastric  catarrh  may  arise  by  extension  from  adjacent 
disease,  as,  for  instance,  in  connection  with  intestinal  catarrh  or 
peritonitis. 

Anatomic  Alterations. — Little  is  definitely  known  with 
regard  to  the  anatomic  alterations  of  acute  gastric  catarrh  in 
human  beings,  because  opportunity  is  seldom  afforded  for  post- 
mortem examination.  The  principal  alterations  usually  involve 
the  pyloric  region,  and  consist  in  redness  and  swelling  of  the 
mucous  membrane  and  increased  secretion  of  mucus.  Microscop- 
ically granular  cloudiness  of  the  main  cells,  the  glands,  hyperemia 
of  the  blood-vessels,  and  proliferation  of  round  cells  in  the  gastric 
raucous  membrane  will  be  apparent. 

Symptoms  and  Diagnosis. — Among  the  symptoms  of  acute 
gastric  catarrh  the  most  constant  is  loss  of  appetite — anorexia.  In 
some  cases  there  is  a  desire  for  piquant  and  highly  salted  or  acid 
articles  of  food  particularly.  Thirst  is  usually  increased.  Not 
only  the  sight,  but  also  the  thought,  of  food  excites  disgust  and 
nausea.  Often  vomiting  occurs,  the  food  not  rarely  being  expelled 
in  a  state  of  fermentation  and  decomposition.  When  vomiting  is 
repeated  the  ejected  matters  not  rarely  acquire  a  greenish  color 
from  admixture  with  biliary  coloring-matter.  Often  the  patients 
complain  that  the  vomited  matters  possess  a  bitter  taste,  which 
may  be  due  not  alone  to  the  biliary  coloring-matter,  but  also  to 
the  peptone  present.  In  less  severe  cases,  or  in  connection  with 
previous  vomiting,  there  occurs  frequently  eructation — singultus.^ 
Often  acid  or  rancid  gases  are  thus  expelled,  which  at  times  dif- 
fuse an  odor  of  hydrogen  sulphid.  Acid  gastric  contents  also  are 
sometimes  brought  up,  leaving  in  the  epigastrium  or  in  the  lower 
segment  of  the  esophagus  a  burning,  boring  sensation,  which  is 
known  as  heartburn — pyrosis. 

Local  examination  of  the  stomach  usually  discloses  extensive 
tenderness  on  pressure  in  the  epigastrium,  M'hich  is  at  times  dis- 
tended with  gas  like  an  air-cushion.  The  patients  also  often 
complain  of  a  sense  of  tension,  of  pressure,  or  of  pain  in  the 
epigastric  region.  The  functions  of  the  stomach  are  altered  in  so 
far  as  the  secretion  of  hydrochloric  acid  ceases,  while  mucus  is 
produced  in  increased  amount.  The  motor  activity  of  the  stomach 
is  diminished,  and  the  food  therefore  remains  in  the  stomach  for 
an  unduly  long  time.  The  tongue  is  usually  coated,  and  a  dis- 
agreeable odor  often  emanates  from  the  mouth.  The  patient  fre- 
quently complains  of  a  pasty  taste.  Frequently  tlie  bowels  are 
irregular,  sometimes  constipation,  sometimes  diarrhea,  existing.  The 
urine  is  not  rarely  voided  in  small  amount,  presenting  a  deep-red, 
highly  concentrated  or  saturated  color,  and  frequently  depositing 
a  brick-dust  sediment  of  urates.     The  disorder  is  at  times  attended 

^  In  English,  eructation  is  synonymous  with  belching,  and  singultus  with 
hiccup. — A.  A.  E. 


212  DIGESTIVE  ORGANS 

^\•ith  slii2:ht  fever — gastric  fever.  It  is  noteworthy  that  the  gen- 
eral condition  may  be  greatly  disturbed.  Vertigo,  mental  eoiii'u- 
siun,  and  headaclie  are  frequently  recurring  symptoms,  and  are 
perlia2)s  to  be  attributed  to  tlie  action  upon  the  central  nervous 
system  of  toxins  formed  in  the  stomach.  The  frequent  occur- 
rence of  facial  herpes,  especially  labial  herpes,  is  perhaps  also  due 
to  toxic  effects  upon  peripheral  nerves.  The  duration  of  acute 
r/astric  catarrh  varies  between  days  and  one  or  two  weeks. 
Relapses  are  extremely  common  in  the  presence  of  recurring  in- 
jurious influences,  and  these  readily  lead  finally  to  the  develop- 
ment of  chronic  gastric  catarrh. 

Prognosis. — Acute  gastric  catarrh  is  not  a  fatal  disease,  and 
the  prognosis  is  therefore  favorable.  With  the  cooperation  of  the 
patient  relapses  can  be  generally  avoided. 

Treatment. — In  the  treatment  of  diseases  of  the  stomach  in 
general  and  particularly  in  that  of  acute  gastric  catarrh  the  great- 
est importance  should  be  attached  not  to  the  administration  of 
numerous  medicaments,  but  to  appropriate  dietetic  regulations. 
Solid  food  should  be  entirely  prohibited,  and  only  weak  tea, 
broths,  milk-soup,  and  mucilaginous  soups  permitted.  Abstinence 
from  food  is  the  best  treatment.  Causal  indications  are  present 
when  the  stomach  has  been  overloaded.  The  viscus  should  tlien 
be  emptied  by  means  of  an  emetic,  most  serviceably  by  apo- 
morphin  hydrochlorate  (0.2  :  10 ;  8  minims  subcutaneously).  If 
the  sense  of  pressure  and  of  pain  be  excessive,  a  hot  cataplasm 
should  be  applied  to  ihe  epigastrium.  Symptomatically,  (Jidde 
hydrochloric  acid  (10  drops  in  a  wine-glassful  of  tepid  water  half 
an  hour  after  meals)  may  be  prescribed.  For  the  relief  of  heartburn 
alkalies,  as,  for  instance,  sodium  bicarbonate  (from  10  to  20  grains) 
or  lime-water  (1  tablespoonful)  or  mineral  waters,  may  be  given. 
Vertigo  and  headache  may  be  relieved  by  antipyrin  or  phenacetin 
(1.0 — 15  grains — thrice  daily). 

CHRONIC  GASTRIC  CATARRH. 

Ktiology. — Errors  in  diet  are  also  the  most  common  cause  of 
chronic  gastric  catarrh.  Irregularity  and  nndue  haste  in  eating 
are  especially  important,  so  that  tlie  food  is  not  sufficiently  masti- 
cated. Those  engaged  in  certain  pursuits  (merchants,  lawyers, 
physicians)  suffer  from  this  disorder  with  esjiecial  frequency, 
because  the  influences  named  are  particularly  operative  among 
them.  Defective  teeth  are  also  responsible  for  the  entrance  of  the 
food  into  the  stomach  in  an  imperfectly  prepared  state,  Xot 
rarely  acute  gastric  catarrh  if  frequently  repeated  gradually  passes 
into  the  chronic  f)rui.  An  unfortunately  common  variety  of 
chronic  gastric  catarrh  is  that  known  as  drunkards^  catarrh,  from 
Avhich  tliose  who  indulge  in  alcoholic  excess  frequently  suffer.  Heavy 


CHRONIC  GASTRIC  CATARRH  213 

smokers  also  are  not  rarely  the  victims  of  chronic  gastric  catarrh. 
Under  both  of  the  last-named  conditions  toxic  influences  are  oper- 
ative. Hypostatic  gastric  catarrh  occurs  especially  in  association 
Avith  chronic  diseases  of  the  respiratory  and  circulatory  organs, 
and  with  diseases  of  the  liver,  especially  cirrhosis.  Cachectic  and 
anemic  gastric  catarrh  develop  in  the  course  of  chronic  disease 
attended  with  impoverishment  of  the  blood  and  Avasting  discharges. 
At  times  chronic  gastric  catarrh  occurs  in  conjunction  with  other 
diseases  of  the  stomach,  as,  for  instance,  carcinoma.  From  the 
nature  of  the  causative  factors  chronic  gastric  catarrh  is  most  com- 
mon in  men,  and  it  occurs  almost  exclusively  in  adults. 

Anatomic  Alterations. — The  anatomic  alterations  of  chronic 
gastric  catarrh  involve  the  pyloric  region  by  preference.  The  mucous 
membrane  is  usually  covered  with  an  abundance  of  mucus,  which  in 
places  is  turbid  and  pus-like,  and  may  even  be  bloody  or  brownish 
in  color.  In  addition  the  mucous  membrane  presents  a  brownish- 
red  appearance,  and  it  exhibits  here  and  there  dilated  vessels  and 
extravasations  of  blood.  At  the  same  time  the  nuicous  membrane 
is  notably  swollen  and  thickened. 

On  microscopic  examination  the  superficial  epithelium  of  the  gastric 
mucous  membrane  will  be  found  involved  in  marked  mucoid  degeneration. 
The  glandular  cells  exhibit  granular  turbidity,  are  in  part  shrunken  and 
uniform,  so  that  the  differentiation  between  the  parietal  cells  and  the  chief 
cells  is  lost.  Accumulation  of  round  cells  in  greater  or  lesser  number  has 
taken  place  between  the  gland-tubules.  The  blood-vessels  are  dilated  and 
greatly  distended.  Xot  rarely  remains  of  blood-pigment  are  present,  indi- 
cating preceding  hemorrhage.    . 

Chronic  gastric  catarrh  readily  gives  rise  to  inflammatory 
hyperplasia  of  the  submucosa,  and  even  of  the  muscularis  and  the 
serosa,  and  under  such  conditions  the  designation  hypertrophic  gas- 
tric catarrh  may  be  employed.  In  consequence  of  excessive 
hyperplasia  of  the  submucosa  in  places  the  mucous  membrane 
sometimes  presents  numerous  wart-like  elevations,  and  there 
results  the  condition  described  as  etat  mamelonne.  At  times  the 
hyperplastic  tissue  undergoes  cicatricial  contraction,  and  the 
stomach  undergoes  the  change  known  as  cirrhosis.  If  circum- 
scribed hyperplasia  of  the  mucous  membrane  take  place,  there  form 
under  some  conditions  numerous  pendulous  tumors,  or  gastric 
polypi — so-called  chronic  poh/pous  gastritis.  Excessive  prolifera- 
tion of  round  cells  between  the  glands  may  cause  atrophy  of  the 
latter  by  pressure,  and,  if  at  the  same  time,  in  consequence  of  pre- 
ceding hemorrhage,  much  gray  or  blackish  pigment  be  present  in 
the  mucous  membrane,  the  condition  is  designated  atrophic  pig- 
mentary induration  of  the  gastric  mucous  membrane.  At  times 
almost  the  whole  of  the  glandular  structure  is  destroyed,  so  that 
the  mucous  membrane  resembles  granulation-tissue,  and  the  con- 
dition   is    then    known  as  chronic  atrophic  gastritis,   or  j)fiihisis 


214  DIGESTIVE  ORGANS 

ventrlcuU,  or  gastric  anadenia.  Finally,  it  may  be  that  some 
glands,  after  occlusion  of  the  excretory  duct,  are  transformed  into 
cystic  cavities — so-called  chronic  ci/dic  (jadritis. 

Symptoms  and  Diagnosis. — The  symptoms  of  chronic 
gastric  catarrh  rcscailjlc  in  many  respects  those  of  acute  gastritis, 
but  tlie  peculiarities  of  an  acute  disorder  are  wanting.  Alterations 
in  appetite  are  among  the  most  constant  symptoms.  Usually  there 
is  anorexia,  but  at  times  there  may  be  bulimia,  and  especially  a 
desire  for  piquant  articles  of  food.  Thirst  is  often,  but  not  always, 
increased.  Generally  the  tongue  presents  a  grayish  or  brownish 
deposit,  and  the  patient  often  complains  of  an  unpleasant  and  pasty 
taste.  Not  rarely  a  disagreeable  odor  emanates  from  the  mouth. 
At  times  tiiere  is  increased  secretion  of  saliva.  Frequently  there 
is  troublesome  eructation — singultus,  ^^■hich  often  is  followed  by 
heartburn — pyrosis.  The  gases  brought  up  by  eructation  not  rarely 
taste  and  smell  rancid  or  acid.  Vomiting  occurs  less  commonly 
with  chronic  than  with  acute  gastric  catarrh.  The  vomited  mat- 
ters often  consist  of  rancid  or  acid  fermenting  gastric  contents,  in 
which  microscopic  examination  discloses  the  presence  of  yeast- 
fungi  and  sarcin?e.  Drunkards  frequently  suffer  in  the  morning, 
when  the  stomach  is  empty,  from  distressing  retching  and  vomiting 
of  masses  resembling  saliva,  and  which  consist  of  saliva  swal- 
lowed during  the  night,  and  less  commonly  of  carbohydrates  that 
have  undergone  mucoid  fermentation.  This  manifestation  is 
known  as  the  morning  vomiting  of  chnmkards.  The  epigastrium  is 
not  rarely  tender  upon  pressure  throughout  an  extensive  area.  The 
functions  of  the  stomach  are  variously  altered.  The  motor  function 
of  the  stomach  is  impaired  with  especial  constancy,  so  that  the 
food  is  retained  in  the  stomach  for  an  unduly  long  time  and  readily 
undergoes  decomposition.  Absorption  on  the  part  of  the  gastric 
mucous  membrane  also  is  almost  always  delayed.  In  the  less 
severe  cases  (simple  chronic  gastric  catarrh)  the  secretion  of  hydro- 
chloric acid  is  diminished,  M'hile  in  the  more  severe  cases  (chronic 
mucous  gastric  catarrh)  free  hydrochloric  acid  is  wanting  in 
the  gastric  contents.  When  anadenia  exists,  not  only  is  hydro- 
chloric acid  wanting,  but  also  pepsin  and  lab-ferment.  The  bowels 
are  usually  constipated  and  irregular.  Urine  is  generally  voided 
in  small  amounts;  often  on  cooling  a  red  granular,  brick-dust 
sediment  of  urates  is  precipitated. 

Frequently  mental  manifestations  are  associated  with  chronic 
gastric  catarrh.  The  patients  become  hypochondriacal,  prefer  to 
be  alone,  are  disinclined  to  mental  and  physical  activity,  and 
oppress  themselves  with  the  most  dismal  reflections  as  to  their 
future.  Imperative  conceptions  and  fear  of  places — agoraphobia — 
also  occur.  Often  com])laint  is  made  of  mental  confusion,  a  sense 
of  beating  in  the  head,  or  headache.  Vertigo  occurs  with  especial 
frequency — so-called  gastric  vertigo — which  usually  is  particularly 


CHRONIC  GASTRIC  CATARRH  215 

noticeable  in  the  morning.  Some  patients  complain  of  palpitation 
of  the  Jteart  and  of  irregularity  in  the  action  of  the  heart.  Asth- 
matic conditions  arise  also  in  connection  with  marked  distention 
of  the  stomach  with  gas — dyspeptic  asthma. 

Chronic  gastric  catarrh  is  unattended  with  fever.  At  times 
emaciation  and  earthy  pallor  become  so  pronounced  that  latent 
gastric  carcinoma  is  rather  suspected.  Anemia  of  high  grade  with 
its  sequels  develops  in  conjunction  with  gastric  anadenia,  and  the 
clinical  picture  may  then  entirely  resemble  that  of  progressive 
pernicious  anemia. 

The  duration  of  the  disease  is  extremely  variable.  Some  patients 
suffer  for  years,  and  even  throughout  life,  from  chronic  gastric 
catarrh.  Among  the  sequels  dilatation  of  the  stomach — gastrectasis 
— may  be  mentioned  particularly,  but  carcinoma  of  the  stomach  also 
is  by  no  means  rarely  a  sequel  of  chronic  gastric  catarrh. 

Prognosis. — The  prognosis  depends  not  rarely  upon  the 
cooperation  of  the  patient,  and  upon  his  willingness  to  forego 
excesses  in  eating  and  in  the  use  of  alcohol  and  tobacco.  In- 
curable causative  factors  naturally  render  the  prognosis  unfavor- 
able. 

Treatment. — The  treatment  should  be  in  the  first  place  causal 
and  at  the  same  time  prophylactic.  The  patient  should  be  advised 
to  eat  slowly  and  with  regularity,  taking  care  to  masticate  the 
food  thoroughly  and  to  keep  the  teeth  in  good  condition.  Drunk- 
ards must  give  up  the  use  of  alcohol,  and  smokers  be  restricted  in 
that  of  tobacco.  The  symptomatic  treatment  depends  upon  the 
nature  of  the  gastric  disturbances.  If  the  gastric  contents  are  free 
from  hydrochloric  acid,  dilute  hydrochloric  acid,  (10  drops  in  a 
wine-glassful  of  tepid  water  half  an  hour  after  meals)  should  be 
prescribed.  To  the  hydrochloric  acid  from  o  to  10  grains  of  j^epsin 
should  be  added,  if  this  also  be  absent  from  the  gastric  juice.  If 
active  fermentation  take  place  in  the  gastric  contents,  systematic 
irrigation  of  the  stomach  by  means  of  a  siphon-arrangement  should 
be  practised.  Only  rarely  will  it  be  possible  to  correct  gastric  fer- 
mentation by  the  internal  administration  of  antizymotics,  as,  for 
instance  : 

R     Salicylic  acid,  0.5    (7 J  grains); 

Saccharin,  0.02  (  ^  grain). — M. 

Make  10  such  starch-capsules. 
l3ose :  1  capsule  thrice  daily  half  an  hour  before  eating. 

R     Resorcin,  0.1    (1}  grains) ; 

Saccharin,  0.02  (  |  grain). — M. 

Make  10  such  powders. 
Dose  :  1  powder  thrice  daily  half  an  hour  before  eating. 

Prolonged  stasis  of  food  in  the  stomach  may  at  times  be  overcome 
by  administration  of  bitters,  which  improve  the  tone  of  the  gastric 
musculature,  as,  for  instance  : 


21 G  DIGESTIVE  ORGANS 


Or, 


R     Strychnin  nitrate,  0.1  (lo  grains) ; 

Powdered  altliea-root,  sufficient  to  make  15  pills. 
Dose :  1  pill  tiirice  daily. 


\i     Wine  of  condurango,  200.0. 

Dose  :  1  tablespoont'ul  thrice  daily. 


Water-cures  are  much  employed,  and  those  that  can  be  carried 
out  at  batliing-resorts,  where  the  diet  is  strictly  regidated,  are 
especially  commendable.  Carlsbad  serves  as  au  example.  In 
general,  alkaline  mineral  springs  (Neuenahr,  Yichy,  Bilin,  Giess- 
hiibel,  Fachingen),  alkaliue-chlorin  springs  (Ems,  Selters,  Gleich- 
enberg),  alkaline-saline  sjmngs  (Carlsbad,  Marienbad,  Franzensbad, 
Tarasp),  and  sodium-chlorid  springs  (Wiesbaden,  Homburg,  Kis- 
singen)  are  worthy  of  consideration.  Residence  in  the  mountains 
and  pedestrian  tours  in  the  mountains  also  may  be  recommended, 
and  they  frequently  exert  a  useful  influence  upon  the  mental  state. 


SUPPURATIVE  INFLAMMATION  OF  THE  STOMACH 
(PURULENT  OR  PHLEGMONOUS  GASTRITIS). 

Purulent  gastritis  is  an  extremely  rare  disease.  It  is  attended 
Avith  suppuration  in  the  submucosa,  the  pus  either  infiltrating  the 
tissues  in  a  diffuse  manner  or  collecting  in  a  circumscribed  manner 
into  an  abscess.  At  times  the  pus  has  been  partially  evacuated 
into  the  cavitv  of  the  stomach  or  into  the  peritoneal  cavity,  and 
perforation  may  take  place  through  numerous  cribriform  openings. 
Often  purulent  peritonitis  develops.  Signs  of  general  septicemia, 
especially  enlargement  and  softening  of  the  spleen,  are  frequently 
observed.  The  causes  are  either  of  infectious  or  of  toxic  nature. 
Thus,  phlegmonous  gastritis  is  at  times  observed  to  develop  in 
the  sequence  of  infectious  diseases.  At  other  times  it  is  associated 
with  other  disease^  of  the  stomach — as,  for  instance,  carcinoma — or 
the  inflammatory  j^rocess  has  extended  from  the  pharynx  or  the 
esophagus  to  the  submucosa  of  the  stomach.  Poisoning  with  cor- 
rosive acids  and  alkalies,  and  excessive  indulgence  in  alcohol  may 
also  be  mentioned  as  causes.  Recognition  of  the  disease  is  scarcely 
possible.  It  is  often  concealed  behind  the  clinical  picture  of  r/ener(d 
septicemia  or  peritonitis.  Fever,  epigastric  pain,  and  vomiting  are 
particularly  constant  manifestations.  The  disorder  would  be  most 
readily  recognized  if  a  tumor  in  the  epigastrium  becomes  smaller 
or  disappears  after  the  vomiting  of  pus.  Death  usually  occurs 
within  a  few  days  amid  signs  of  ]irogressive  asthneia.  Recovery 
with  cicatrization  ^irobably  takes  place  but  rarely. 

The  treatment  consists  in  the  administration  of  stimulants, 
the  swallowing  of  bits  of  ice,  and  the  application  of  an  ice-bag  to 
the  epigastrium. 


ROUND    ULCER   OF  THE  STOMACH  217 

ROUND  ULCER  OF  THE  STOMACH. 

Htiology. — Round  ulcer  of  the  st'omach  is  a  common  disorder 
that  in  some  regions  attacks  more  than  5  per  cent,  of  the  popula- 
tion. Childhood  is  usually  exempt  from  the  disease,  while  the 
age  between  the  fifteenth  and  the  thirtieth  year  of  life  suffers 
especially.  Women  are  attacked  more  than  twice  as  commonly 
as  men.  The  disorder  develops  with  striking  frequency  in  the 
sequence  of  chlorosis,  in  consequence,  it  is  thought,  of  anemic 
fatty  degeneration  of  the  blood-vessels  of  the  stomach,  and  throm- 
bosis in  the  diseased  areas.  At  times  the  ingestion  of  hot  articles 
of  food  is  followed  by  the  formation  of  a  round  ulcer  of  the  stom- 
ach. The  disease  is,  therefore,  observed  with  unusual  frequency 
in  cooks.  Traumatism  in  the  epigastric  region,  as,  for  instance, 
a  severe  blow,  may  act  as  a  cause  of  the  disorder.  In  this  group 
of  etiologic  factors  may  be  included  also  violent  efforts  at  vomit- 
ing, which  may  give  rise  to  hemorrhage  and  to  hemorrhagic  ero- 
sion of  the  gastric  mucous  membrane,  and  secondarily  to  gastric 
ulceration.  Certain  infectious  diseases,  particularly  pulmonary 
tuberculosis  and  syphilis,  have  been  made  responsible  for  the 
development  of  round  ulcer  of  the  stomach,  but  this  supposition 
still  requires  confirmatory  evidence.  At  times  round  ulcer  of  the 
stomach,  like  ulceration  of  the  duodenal  mucous  membrane,  has 
been  observed  to  develop  after  extensive  burns  of  the  skin,  perhaps 
in  consequence  of  thrombosis  of  gastric  vessels  by  blood-plates. 
Further,  the  predisposition  to  round  ulcer  of  the  stomach  may  be 
augmented  by  certain  injurious  influences  acting  upon  the  stom- 
ach, among  which  may  be  named  the  ingestion  of  starchy  food 
and  of  alcohol  in  excessive  amounts. 

Anatomic  Alterations. — The  round  ulcer  of  the  stomach 
acquires  its  name  from  its  shape.  It  is  generally  round,  and  if  it 
is  confined  to  the  gastric  mucous  membrane  it  presents  an  appear- 
ance as  if  the  mucous  membrane  in  the  diseased  situation  had 
been  cut  out  with  a  punch.  It  is,  therefore,  characterized  by  its 
sharp  borders,  which  usually  are  but  little  elevated,  and  on  micro- 
scopic examination  exhibit  slight  alterations  (round-cell  infiltra- 
tion). The  muscular  layer  of  the  stomach  is  not  rarely  exposed 
in  the  floor  of  the  ulcer,  as  if  it  had  been  artificially  dissected  out 
with  a  knife.  The  ulcer  varies  in  size.  At  times  it  is  so  small 
that  it  may  be  readily  overlooked,  while  at  other  times  it  may 
attain  the  size  of  the  palm  of  the  hand.  It  is  most  frequently 
situcded  in  the  neighborhood  of  the  pylorus  and  upon  the  posterior 
w^all  of  the  stomach,  and  least  commonly  at  the  cardia.  Usually 
but  a  single  ulcer  is  present.  If  there  are  several,  they  may  be  in 
various  stages  of  development.  At  times  contiguous  ulcers  coa- 
lesce, and  as  a  result  irregular  excavated  losses  of  tissue  take 
place.      Not   rarely   the   ulcerative   process    extends    from    the 


218  DIGESTIVE  ORGANS 

iiuK'oiis  membrane  to  the  muscular  layer,  and  even  to  the  serosa. 
Such  a  condition  is  attended  with  danger  of  rupture  of  the  Htom- 
fU'h,  and  this  accident  occurs  with  such  frequency  that  the  round 
ulcer  of  the  stomach  has  also  been  designated  perforating  ulcer 
of  the  stomach.  Fortunately,  free  rupture  of  the  stomach  into 
the  peritoneal  cavity  is  frequently  averted  by  the  formation  of 
adhesions  between  the  stomach  and  adjacent  organs,  as  with  the 
liver,  the  pancreas,  or  the  spleen,  as  a  result  of  previous  circum- 
scribed peritonitis.  At  the  same  time  the  destructive  process 
may  also  extend  to  these  organs,  and  give  rise  to  alarming  hemor- 
rhage by  perforation  of  large  blood-vessels.  The  borders  of  deep 
ulcers  are  sometimes  terrace-like,  and  usually  steeper  upon  one 
side  than  upon  the  other.  The  ulcer  is  sometimes  funnel-shaped, 
with  its  broad  base  directed  toward  the  gastric  muccnis  membrane. 
The  apex  of  the  funnel,  however,  is  not  situated  vertically  over 
the  center  of  the  base,  but  eccentrically.  The  entire  shape  of  the 
ulcer  is  suo-gestive  of  the  mode  of  division  of  the  2:astric  vessels, 
and  the  impression  is  created  as  if  the  distribution  of  a  gastric 
artery  had  been  involved  in  the  ulcerative  process.  If  a  gastric 
ulcer  undergoes  cicatrization,  the  mucous  membrane  in  the  vicinity 
of  the  margin  of  the  ulcer  is  often  thrown  into  radiatino;  folds. 
Gastric  cicatrices  at  the  pylorus  not  rarely  are  followed  by  ste- 
nosis at  this  orifice  and  dilatation  of  the  stomach.  By  contrac- 
tion cicatrices  may  give  rise  to  deformities  of  the  stomach.  At 
times  cicatrices  at  the  middle  of  the  stomach  may  cause  the  stom- 
ach to  assume  tlie  shape  of  an  hour-glass. 

Symptoms  and  Diagnosis. — Occasionally  gastric  ulcer  is 
wholly  unattended  with  symptoms,  and  is  accidentally  discovered 
on  post-mortem  examination — latent  gastric  ulcer.  In  other  in- 
stances the  development  of  a  gastric  ulcer  is  insidious,  but  hemor- 
rhage or  perforation  takes  place  suddenly,  and  may  cause  death 
within  a  short  time.  Among  all  the  symptoms  of  round  ulcer 
of  the  stomach,  hemorrliage  from  the  stomach — gastrorrhagia — is 
the  most  reliable  in  diagnosis.  In  its  al)sencc  the  diagnosis  will 
only  be  more  or  less  probable.  Hemorrhage  from  the  stomach 
takes  place,  however,  in  but  one-third  of  the  cases,  and  its  occur- 
rence depends  upon  whether  vessels  of  considerable  size  are  per- 
forated by  the  ulcerative  process  before  thrombosis  has  taken 
place.  Most  frequently  hemorrhage  from  the  stomach  gives  rise 
to  the  vomiting  of  blood — hematemesis.  The  vomited  blood 
appears  as  dark-red.  partly  coagulated  masses,  is  often  admixed 
with  particles  of  food,  and  usually  yields  an  acid  reaction.  The 
loss  of  blood  mav  be  so  consideral)le  as  to  render  death  imminent. 
The  patients  present  a  cadaveric  jiallor,  with  a  soft,  small,  and 
dicrotic  pulse,  feeble  heart-sounds,  often  systolic  heart-murmurs, 
and  dilatation  of  the  right  ventricle.  Not  rarely  albuminuria 
develops,  with  slight  edema  about  the  ankles,  and  even  edema 


ROUND    ULCER   OF  THE  STOMACH       '  219 

of  the  face.  In  consequence  of  cerebral  anemia  attacks  of  syn- 
cope occur,  especially  upon  assuming  the  upright  posture,  with 
roaring  in  the  ears,  impairment  of  hearing,  blurring  of  vision, 
palpitation  of  the  heart,  and  shortness  of  breath.  Death  takes 
place  amid  chronic  convulsions.  At  times  blindness  follows 
recovery  from  gastric  hemorrhage. 

Much  less  commonly  hemorrhage  from  the  stomach  is  attended  with 
coffee-ground,  ink-like,  or  soot-like  vomiting,  which,  on  the  other  hand,  is 
common  with  gastric  carcinoma.  It  occurs  with  gastric  ulcer  when  but 
small  hemorrhages  have  taken  place,  and  the  blood  remains  in  the  stomach 
for  a  considerable  time,  in  consequence  of  which  the  hemoglobin  is  con- 
verted into  hematin  by  the  hydrochloric  acid  of  the  gastric  juice. 

Far  less  commonly  hemorrhage  from  the  stomach  is  unat- 
tended with  hematemesis,  but  discharge  of  blood  takes  place 
from  the  bowel,  as  manifested  by  the  appearance  of  black,  tarry 
stools.  This  occurrence  must  always  be  thought  of  when  patients 
suddenly  lose  consciousness  at  stool  and  become  pale.  Not  rarely 
slight  febrile  movement  occurs,  probably  in  consequence  of  absorp- 
tion of  decomposed  blood  from  the  intestine  into  the  circulation. 
It  is  rare  for  hemorrhage  from  the  stomach  always  to  be  mani- 
fested by  bloody  stools  alone.  More  frequently  bloody  vomiting 
occurs  in  conjunction  with  bloody  stools. 

Epigastric  pain — gastralgia — is  an  exceedingly  common  symp- 
tom of  gastric  ulcer,  but  it  is  of  varied  significance.  Pain  in  the 
epigastrium  appears  usually  a  short  time  after  the  ingestion  of 
food,  and  is  readily  induced  by  inappropriate  food.  Palpation 
of  the  stomach  also  induces  pain,  and  especial  consideration  should 
be  given  to  the  fact  that  this  pain  is  confined  to  a  circumscribed 
area.  At  times  pain  in  the  stomach  appears  in  certain  postures, 
as,  for  instance,  the  lateral  decubitus.  The  functions  of  the  stomach 
exhibit  no  peculiarity.  The  period  of  absorption  is  generally  pro- 
longed, rarely  shortened.  The  hydrochloric  acid  of  the  gastric 
juice  is  often,  but  by  no  means  constantly,  increased  (more  than 
0.25  per  cent.).  The  motor  functions  of  the  stomach  exhibit  no 
alteration.  The  patients  often  complain  of  frequent  and  persistent 
vomiting.  Some  scarcely  retain  food  for  weeks  and  months,  and 
alarming  emaciation  may  result.  Eructation  and  pyrosis  are  not 
uncommon  symptoms.  The  appetite  is  usually  wanting,  while 
thirst  is  increased.  In  patients  in  whom  vomiting  is  frequent  the 
tongue  often  presents  a  vivid-red  color  and  a  clean  appearance, 
probably  in  consequence  of  irritation  due  to  the  marked  acidity 
of  the  vomited  matters.  Individuals  with  round  ulcer  of  the 
stomach,  as  a  rule,  emaciate  rapidly  and  acquire  a  pallid  appear- 
ance. Often  they  become  extremely  nervous  and  sleepless.  Even 
when  cicatrization  of  the  ulcer  takes  place,  they  must  frequently 
be  careful  in  eating  and  drinking  throughout  life. 

The  duration  of  the  disease  usually  extends  over  several  months. 


220  DIGESTIVE  ORGANS 

whence  the  name  chronic  gastric  ulcer.  Besides,  there  is  a  great 
tendency  to  recurrence,  so  that  some  patients,  in  spite  of  all  care, 
are  annoyed  and  alarmed  from  time  to  time  by  renewed  symptoms 
of  gastric  ulceration.  Among  the  compdcdtionii  of  round  ulcer  of 
the  stomach  the  most  frequent,  and  diagnostically  tiie  most  impor- 
tant, has  already  been  mentioned,  namely,  hemorrhage  from  the 
stomach.  Another  serious  complication  consists  in  peritonitis  and 
perforative  peritonitis.  Simple  ])eritonitis  is  generally  confined  to 
the  immediate  vicinity  of  the  ulcer.  Perforative  peritonitis  as  a 
rule  sets  in  abruptly,  and  gives  rise  to  alarming  collapse.  The 
abdomen  becomes  distended,  tense,  and  universally  tender  on 
pressure,  hepatic  and  splenic  dulness  have  disappeared,  and  death 
results  often  within  a  short  time. 

Perforation  of  the  ulcer  takes  place  less  commonly  into  the  bowel, 
through  the  diaphragm  into  the  pleural  or  the  pericardial  cavity,  and  even 
into  the  lungs  or  into  the  heart,  than  into  the  abdominal  cavit}'.  A  sub- 
phrenic abscess  may  also  develop  in  consequence  of  perforation  of  a  gastric 
ulcer. 

Among  complications  gastralgia  and  great  sensitiveness  of  the 
stomach  should  be  especially  mentioned,  and  these  may  occasion- 
ally persist  throughout  life.  Cicatrized  ulcers  at  the  pylorus  may 
give  rise  to  pyloric  stenosis  and  dilatation  of  the  stomach.  Destruc- 
tion of  the  muscular  ring  of  the  pylorus  is  followed  by  jyyloric 
insujficiency.  Especial  significance  should  be  attached  to  the  fact 
that  at  times  in  advanced  life  carcinoma  develops  at  the  border 
of  a  gastric  ulcer. 

Opinions  are  divided  as  to  the  pathogenesis  of  round  ulcer  of  the  stomach. 
In  our  opinion  local  disturbances  in  the  circulation  in  the  gastric  mucous 
membrane  constitute  the  first  alteration.  In  favor  of  this  view  is  the  shape 
of  the  ulcer,  which  often  reproduces  the  area  of  distribution  of  a  blood- 
vessel of  moderate  size.  At  times  thrombotic  occlusion  may  have  taken 
place,  at  other  times  rupture  of  a  blood-vessel  with  hemorrhage.  The  por- 
tion of  gastric  mucous  membrane  cut  off  from  its  blood-supply  may  be 
digested  by  the  gastric  juice,  a  process  that  is  prevented  under  normal  cir- 
culatory conditions  by  the  alkalinity  of  the  blood.  If  in  addition  hyper- 
acidity of  the  gastric  juice  be  present,  digestion  is  favored  in  a  still  greater 
degree.  The  round  ulcer  of  the  stomach  nuiy,  therefore,  be  designated  a 
peptic  ulcer.  Possibly  bacteria  also  take  some  part  in  the  destruction  of  the 
gastric  mucous  membrane. 

Prognosis. — The  prognosis  of  round  ulcer  of  the  stomach  is 
always  grave,  for  of  the  most  dangerous  complications  there  is  no 
small  number,  and  these  may  occur  unexpectedly  in  spite  of  all 
watchfulnoss  over  the  patient. 

Treatment. — In  the  treatment  of  round  ulcer  of  the  stom- 
ach diet  plays  an  important  ])art.  As  long  as  the  ulcer  has  not 
undergone  cicatrization  the  patient  should  remain  in  bed  and  keep 
a  hot  cataplasm  constantly  applied  to  the  epigastrium.  Only  liquid 
and  unirritating  food  should  be  permitted.  A  milk-diet  is  the  best. 
The  milk,  after  thorough  boiling,  should  be  taken  in  small  swallows 


ROUND    ULCER   OF  THE  STOMACH  221 

every  quarter  of  an  hour  to  the  amount  of  one  or  one  and  a  half 
liters  per  day.  For  patients  who  have  an  aversion  to  milk,  Aveak 
tea,  coffee,  or  meat-broth  may  be  added.  Should  milk  not  be 
well  borne,  it  can  be  made  into  a  thin  soup  with  the  aid  of  fine 
flour ;  and  should  it  undergo  fermentation  and  acid  decomposition 
readily  in  the  stomach,  a  tablespoonful  of  lime-water  may  be  added 
to  each  glass.  Some  persons  bear  buttermilk  better,  and  it  will 
then  be  advisable  to  prescribe  a  course  of  buttermilk-treatment. 
If  the  stomach  is  exceedingly  sensitive  to  the  ingestion  of  food, 
it  may  be  necessary  for  a  time  to  forbid  all  food  by  the  mouth,  and 
to  confine  the  feeding  to  nutrient  enemata.  The  simplest  mixture 
for  this  purpose  consists  of  equal  parts  of  milk  and  slightly  salted 
meat-broth,  to  which  some  sugar,  2  raw  eggs,  and  10  drops  of 
tincture  of  opium  may  be  added.  This  mass,  at  the  temperature 
of  the  body,  is  permitted  to  flow  slowly  into  the  rectum  thrice 
daily  in  amounts  up  to  300  c.c.  by  means  of  a  Hegar  funnel,  after 
the  rectum  has  previously  been  cleared  of  fecal  matter  by  irriga- 
tion. The  resumption  of  solid  food  should  be  effected  slowly.  There 
may  then  be  administered  soft-boiled  eggs,  meat-peptone,  calves' 
brain,  scraped  beef,  scraped  ham,  scraped  sirloin,  veal-cutlets,  rice- 
pap,  potato-pap.  With  regard  to  vegetables,  fruits,  and  fatty 
articles  of  food,  care  must  be  taken  for  a  long  time,  often  through- 
out the  remainder  of  life.  Among  medicaments  we  would  espe- 
cially recommend  artificial  Carlsbad  salt  and  bismuth  salicylate. 
Of  the  salt,  1  or  2  teaspoonfuls  should  be  dissolved  in  500  c.c. 
of  tepid  water,  and  this  should  be  drunk  slowly  every  morning 
for  four  weeks  while  the  stomach  is  empty.  The  object  aimed  at 
is  to  diminish  the  hyperacidity  of  the  gastric  juice,  to  remove  from 
the  gastric  mucous  membrane  such  mucus  as  may  be  present,  and 
to  induce  evacuation  of  the  bowels.  The  bismuth  salicylate  is 
intended  to  favor  the  process  of  granulation  and  cicatrization  of 
the  ulcer.  It  is  preferably  given  an  hour  before  meals,  in  order 
that  it  may  readily  reach  the  floor  of  the  ulcer.  If  pain  in  the 
stomach  is  present,  the  bismuth  may  be  combined  with  narcotics ; 
as,  for  instance  : 


-M. 


Should  hemorrhage  from  the  stomach  take  place,  the  patient 
should  at  ouce  be  put  to  bed.  Small  bits  of  ice  may  be  given  and 
be  swallowed,  an  ice-bag  applied  to  the  epigastrium,  about  8  min- 
ims of  fluid  extract  of  ergot  with  an  equal  amount  of  sterile  water 
injected  beneath  the  skin  twice  or  thrice  daily,  and  lead  acetate 
administered  internallv  ;  for  instance  : 


R     Bismuth  salicylate, 

0.5       (7^-  grains)  ; 

Morphin  hydrochlorate, 

0.005  (  xV  grain)  ; 

Extract  of  belladonna, 

0.02     {  i        "     ); 

Sugar, 

0.03     (  ^        "     ).- 

Make  10  sucli  starch-capsules. 

Dose:  1  capsule  thrice  daily  before 

meals. 

222  DIGESTIVE  ORGANS 

R     Lead  acetate,  0.05  (  f  grain) ; 

Powdered  camphor,  0.02  (J     "     ) ; 

Sugar,  0.5    (7^  grains). — M. 

Make  10  such  powders. 
Dose :  1  powder  thrice  daily. 

It  is  advisable  to  administer  no  food  by  the  mouth  for  several 
days,  substituting  nutrient  enemata  of  the  composition  already 
described.  In  ease  of  peritonitis  and  perforative  peritonitin  rest, 
the  application  of  an  ice-bag  to  the  abdomen,  and  administration 
of  opium  (0.03 — \  grain ;  1  powder  every  two  hours)  are  neces- 
sary. Should  collapse  set  in,  15  minims  of  camphorated  oil  should 
be  injected  beneath  the  skin  every  two  or  three  hours.  Surgical 
intervention  has  been  practised  successfully  in  a  number  of  in- 
stances in  the  treatment  of  round  ulcer  of  the  stomach.  Ulcers 
attended  with  uncontrollable  and  dangerous  hemorrhage  have  been 
excised  after  exposure  of  the  stomach,  and  in  cases  of  perforative 
peritonitis  the  abdominal  cavity  has  been  opened,  the  pus  removed 
as  thoroughly  as  possible  by  sponging,  and  the  rupture  closed  by 
suture.  At  times  certain  sequels  of  a  round  ulcer  of  the  stomach 
necessitate  operative  intervention,  as,  for  instance,  cicatricial  steno- 
sis of  the  pylorus  and  hour-glass  contraction  of  the  stomachy 
For  the  relief  of  these  conditions  pyloroplasty  and  gastro-enter- 
ostomy  have  been  practised  with  good  results.  In  the  after-treat- 
ment patients  of  means  should  be  advised  courses  of  treatment  at 
the  springs.  An  especial  reputation  in  this  connection  is  borne 
particularly  by  the  springs  of  Carlsbad. 

CARCINOMA  OF  THE  STOMACH. 

Ktiology. — Carcinoma  of  the  stomach,  like  carcinoma  in 
general,  is  a  disease  of  advanced  life,  usually  developing  after 
the  fortieth  year.  Why  this  period  of  life  is  more  predisposed  to 
carcinoma  is  as  yet  unknown.  Experience  has  shown  that  car- 
cinoma of  the  stomach  is  more  common  in  men  than  in  women.  It 
is  also  observed  more  commonly  in  seme  regions  than  in  others, 
probably  in  consequence  of  local  peculiarities  in  dietetic,  injurious, 
and  irritative  influences  acting  upon  the  stomach.  Without  doubt 
preceding  disease  of  the  stomach  has  an  influence  upon  the  develop- 
ment of  gastric  carcinoma.  Among  such  disorders  are  chronic 
gastric  catarrh,  round  ulcer  of  the  stomach,  and  irritation  of  the 
gastric  mucous  membrane  by  excessive  indulgence  in  alcohol. 
Injuries  in  the  epigastrium  probably  are  not  incorrectly  looked  upon 
as  causes  of  carcinoma.  The  influence  of  heredity,  however,  is 
highly  (loulitful. 

Anatomic  Alterations. — Carcinoma  of  the  stomach  is  almost 
always  of  primary  nature;  but  few  examples  of  secondary  car- 
cinoma of  the  stomach  are  on  record.  The  most  common  seat  is 
the  pylorus,  and  next  in  frequency  are  the  cardia  and  the  lesser 


CARCINOMA   OF  THE  STOMACH  223 

curvature.  The  fundus  almost  always  escapes,  even  when  the 
remainder  of  the  stomach  is  involved  in  the  new-growth.  In  some 
cases  the  tumor  is  circumscribed  and  attached  to  the  gastric  mucous 
membrane  by  a  small  base,  and  not  rarely  presenting  a  cup-shaped 
depression  upon  its  surface.  The  shape  of  the  tumor  has  under 
such  conditions  been  compared  with  the  appearance  of  a  fungous 
growth,  and  on  this  account  it  has  been  designated  a  fungus  of 
the  stomach.  In  other  instances  diffuse  carcinomatous  infiltration 
takes  place,  which  may  attain  a  considerable  extent,  especially  in 
the  subjnucous  connective  tissue,  and  often  sends  medullary  white 
strands  of  carcinomatous  tissue  into  the  connective-tissue  septa  of 
the  muscular  layer  of  the  stomach,  and  even  into  the  serosa.  Tihe 
wall  of  the  stomach  is  often  increased  in  thickness  to  several  centi- 
meters in  the  diseased  area. 

In  accordance  with  the  appearance  of  the  neoplastic  tissue, 
several  varieties  of  carcinoma  of  the  stomach  are  distinguished.  If, 
in  consequence  of  marked  development  of  connective  tissue,  the 
new-growth  is  dense  and  deficient  in  fluid,  it  is  designated  a  fibrous 
carcinoma — scirrhus.  It  is  designated  medullary  or  alveolar  car- 
cinoma when  so-called  "  carcinoma-milk  "  can  be  scraped  without 
difficulty  from  the  carcinomatous  tissue  with  a  knife.  Colloid  or 
gelatinous  carcinoma  is  attended  Avith  the  presence  of  spaces  filled 
with  gelatinous  contents  resembling  isinglass. 

On  microscopic  examination  the  carcinomatous  tumor  is  found  to  be  con- 
stituted of  epithelioid  cells,  which  lie  close  together  in  a  nest-like  arrangement, 
and  in  consequence  of  which  the  individual  collections  of  carcinoma-cells 
are  separated  from  one  another  by  connective-tissue  septa.  The  carcinoma- 
tous tissue  is  developed  as  a  result  of  abnormal  proliferation  of  the  chief 
cells  of  the  lab-glands,  the  proliferation  rapidly  advancing  into  the  sub- 
mucous tissue,  where  it  finds  exceedingly  favorable  conditions  for  its  further 
development.  The  portion  of  gastric  raucous  membrane  involved  in  the 
new-growtb  frequently  exhibits  signs  of  chronic  interglandular  catarrh  and 
even  atrophy  of  the  lab-glands  (anadenia). 

Carcinomatous  tissue  has  a  great  tendency  to  undergo  disinte- 
gration. Therefore  the  superficial  layers  of  the  new-growth  are 
usually  found  destroyed,  and  thus  the  so-called  carcinomatous 
ulcer  is  formed.  In  the  process  of  disintegration  hemorrhage 
from  or  perforation  of  the  stomach  may  readily  take  place.  The 
latter  is  often  averted  by  the  previous  formation  of  adhesions 
between  the  stomach  and  adjacent  organs  in  consequence  of  circum- 
scribed peritonitis.  Generally  the  'perigastric  lympJwtic  glands 
also  undergo  carcinomatous  degeneration  and  are  converted  into 
hard,  nodular  tumors.  Not  rarely  secondary  carcinoma  develops 
in  other  organs,  most  commonlv  in  the  liver. 

Symptoms  and  Diagnosis. — The  symptoms  of  carcinoma 
of  the  stomach  are  in  part  local,  in  part  general.  The  latter  con- 
sist in  manifestations  of  carcinomatous  marasmus,  and  these  occur 
with  especial   readiness  precisely  in  cases  of  carcinoma  of  the 


224  DIGESTIVE  ORGANS 

stomach,  because,  in  addition  to  the  injurious  influences  usually 
exerted  by  carcinoma  upon  the  general  nutrition,  in  cases  of  car- 
cinoma of  the  stomach  the  injurious  effects  of  the  disturbance  of 
gastric  digestion  are  superadded.  As  long  as  local  symptoms  are 
wanting  the  diagnosis  will  remain  doubtful.  Progressive  emacia- 
tion, increasing  pallor  of  the  skin,  and  the  occurrence  of  cachectic 
edema  may,  perliaps,  arouse  suspicion  of  latent  internal  car- 
cinoma, but  its  situation  in  the  stomach  will  be  suggested  only 
when  gastric  disturbances  are  at  the  same  time  present.  Further, 
most  extensive  carcinoma  of  the  stomach  may  exist  in  the  absence 
of  local  symptoms  referable  to  the  stomach. 

Among  all  of  the  local  iiianifestations  the  demonstration  of  a 
tumor  of  the  stomach  is  the  most  important  from  a  diagnostic 
point  of  view.  Usually  this  will  be  appreciable  to  the  right  of 
the  median  line  just  below  the  inferior  margin  of  the  liver,  or  it 
may  extend  from  this  situation  toward  the  left  in  the  course  of 
the  lesser  curvature  of  the  stomach.  As,  however,  under  normal 
conditions  the  pylorus,  as  well  as  the  lesser  curvature  of  the 
stomach,  is  concealed  by  the  liver,  it  follows  that  tumors  in 
the  portions  of  the  stomach  named  will  become  accessible  only 
when  they  have  attained  considerable  size  and,  by  reason  of 
their  weight,  are  capable  of  dragging  the  stomach  downward, 
so  that  as  a  result  the  pylorus  and  the  lesser  curvature  of  the 
stomach  are  directly  applied  to  the  abdominal  wall.  When  the 
abdominal  walls  are  thin  and  emaciated  the  gastric  tumor  is  not 
rarely  visible  as  a  roundish  and  nodular  mass.  On  palpation 
the  growth  will  be  felt  to  be  of  solid  consistence  and  irregularly 
nodular.  Almost  always  it  is  tender,  even  upon  slight  pressure. 
It  is  important  that  in  contradistinction  from  new-growths  of  the 
liver  and  of  the  spleen  displacement  does  not  take  place  with  the 
movements  of  respiration.  Exceptions  to  this  rule  occur  only 
when  the  tumor  is  adherent  to  the  liver,  and  participates  in  its 
respiratory  displacement;  or,  if  the  entire  stomach  is  involved  in 
carcinomatous  degeneration,  so  that,  by  reason  of  the  rigidity  of 
its  walls,  it  is  no  longer  capable  of  yielding  before  the  respiratory 
movement  of  the  diaphragm.  Further,  care  must  be  taken  to 
avoid  confounding  the  respiratory  gliding  of  the  abdominal  walls 
over  the  tumor  with  the  respiratory  movement  of  the  latter  itself. 
Percussion  over  the  gastric  tumor  yields  a  dull-tympanitic  note. 

Carcinomafa  of  the  cnrdia  are  never  accessible  to  examination 
through  the  abdominal  wall,  but  they  can  be  detected  only  with 
the  aid  of  the  esophageal  bougie,  which  encounters  resistance  40 
cm.  (15f  in.)  from  the  edge  of  the  teeth.  The  employment  of  the 
sound  should  never  be  omitted  in  any  doubtfid  case  of  marasmus. 
Auscultation  of  the  stomach  is  also  important.  If  a  patient  with 
carcinomatous  stenosis  of  the  cardia  be  made  to  swallow  fluid, 
there  are  heard,  if  the  stethoscope  is  placed  in  the  angle  between 


CARCINOMA   OF  THE  STOMACH  225 

the  eiisiform  process  and  the  left  costal  margin,  either  after  a  con- 
siderable length  of  time  an  injection-murmur  and  an  expression- 
murmur,  or  after  an  nnusually  long  interval  but  a  single  murmur. 
At  the  same  time  the  murmurs  are  usually  strikingly  loud  and 
long  continued. 

In  the  presence  of  gastric  carcinoma  the  functions  of  the  stomach 
are  not  altered  in  any  such  characteristic  manner  as  to  permit  the 
recognition  of  the  disorder  with  certainty.  Frequently,  almost 
constantly,  the  period  of  absorption,  as  determined  by  the  potas- 
sium-iodid  test,  is  prolonged,  occupying,  instead  of  ten  or  fifteen 
minutes,  as  much  as  from  thirty  to  sixty  minutes,  or  even  more. 
The  motor  activity  of  the  stomach  also  will  be  found  diminished, 
and  foreign  bodies — for  instance,  cherry-pits — may  remain  in  the 
stomach  at  times  for  months.  Hydrochloric  acid  is  almost  always 
wanting  in  the  gastric  contents. 

Boas  has  attached  great  diagnostic  significance  to  the  presence  of  lactic 
acid  in  the  gastric  contents,  but  without  justification. 

Persons  suflPering  from  gastric  carcinoma  complain  principally 
of  severe  epigastric  pain  or  gastralgia.  This  not  rarely  sets  in 
toward  night  and  disturbs  sleep.  Often  there  is  singultus  or 
vomiting.  The  regurgitated  gases  not  rarely  emit  an  offensive 
odor  and  that  of  hydrogen  sulphid.  The  vomited  matters  often 
contain  large  numbers  of  sarcinse,  and  long,  curved  bacilli,  which 
have  been  considered  responsible  for  the  lactic-acid  fermentation 
of  the  gastric  contents.  Of  diagnostic  importance  is  the  occur- 
rence of  small  masses  of  blood  coloring-matter  demonstrable  micro- 
scopically. 

At  times  portions  of  carcinomatous  tissue  may  be  found  in  the  vomited 
matters,  but  this  is  an  uncommon  occurrence. 

Most  patients  with  carcinoma  of  the  stomach  complain  of 
obstinate  loss  of  appetite — anorexia.  Thirst  is  not  rarely  in- 
creased. The  tongue  as  a  rule  is  coated.  In  diagnosis  the  pres- 
ence of  carcinomatous  induration,  and  enlargement  of  the  supra- 
clavicular lymphatic  glands  upon  the  left  side  is  significant.  The 
inguinal  lymphatic  glands,  also,  not  rarely  exhibit  induration  and 
enlargement.  The  urine  is  generally  passed  in  small  amoiuits  ;  it 
is  therefore  usually  deep  red  in  color  and  concentrated,  and  as  a 
rule  contains  much  indican.  The  botvels  are  commonly  consti- 
pated, although  diarrhea  may  occur  periodically.  The  general 
nutrition  usually  suffers  early.  The  patients  emaciate  markedly 
within  a  short  time,  and  acquire  a  pallid  or  waxy-yellow  appear- 
ance. The  latter  is  found  on  examination  of  the  blood  to  be  depend- 
ent upon  diminution  in  the  number  of  red  blood-corpuscles  and  in 
the  amount  of  hemoglobin. 

If  the  anemia  be  advanced,  poikilocytosis  may  be  present.  There  may 
also  be  hemorrhages  into  the  retina,  cutaneous  edema,  and  small  hemorrhages 

15 


226  DIGESTIVE  ORGANS 

and  foci  of  softening  in  the  spinal  cord,  such  as  take  place  in  pernicious 
anemia. 

Death  occurs  within  a  year,  usually  with  progressive  asthenia. 

Among  the  complications  hemorrhage  from  the  stomacli  is  the 
most  conspicuous.  This  often  gives  rise  to  the  vomiting  of  blood — 
hematemesis.  Most  frequently  the  vomited  matters  resemble 
coffee-grounds,  or  ink,  or  soot,  Avhile  less  commonly  fresh  blood  is 
present.  These  variations  are  to  be  explained  by  the  fact  that,  as 
a  rule,  small  blood-vessels  are  opened  in  the  process  of  disintegra- 
tion of  the  carcinomatous  tissue,  so  that  the  small  amounts  of 
blood  extravasated  remain  for  a  considerable  time  in  the  stomach, 
while  the  hemoglobin  undergoes  alterations  in  consequence  of 
the  action  of  the'  acids  of  the  gastric  juice.  Although  hemorrhage 
from  the  stomacli  may  be  repeated  frequently,  it  rarely  causes  death. 
Carcinoma  at  tlie  pylorus  frequently  gives  rise  to  dilatation  of 
the  stomach — gastrectasis.  The  pyloric  ring  may  also  be  destroyed, 
and  pyloric  incontinence  result.  At  times  secondary  carcinoma 
develops  in  other  organs,  and  it  may  divert  attention  from  the 
primarily  involved  stomach.  In  this  connection  secondary  carci- 
noma of  the  liver  especially  should  be  mentioned.  At  times 
rupture  of  the  stomach  takes  place,  sometimes  into  the  abdominal 
cavity,  at  other  times,  after  previous  adhesion  of  the  stomach,  into 
neighboring  organs,  rarely  through  the  anterior  abdominal  wall. 
Carcinoma  of  the  stomach  is  usually  unattended  Avith  fever.  At 
times,  however,  febrile  movement  occurs,  and  it  may  even  be  of 
intermittent  type.  Possibly  it  results  from  the  absorption  of  toxic 
substances  from  the  stomach.  At  times  the  patients  unexpectedly 
become  comatose,  and  die  in  coma.  Such  a  result  has  been  attrib- 
uted to  the  absorption  of  toxic  substances  from  the  stomach ; 
therefore  an  auto-intoxication.  The  urine  frequently,  though  not 
constantly,  exhibits  a  dark-red  color  on  the  addition  of  dilute 
solution  of  ferric  chlorid — so-called   ferric-chlorid  reaction. 

Prognosis. — The  prognosis  of  carcinoma  of  the  stomach  is 
invariably  unfavorable,  as  death  results  at  the  latest  in  the  course 
of  a  few  months. 

Treatment. — No  internal  remedy  is  known  that  is  capable 
of  effecting  a  cure  of  carcinoma  of  the  stomach.  Attempts  have 
been  made  to  bring  about  this  end  by  operative  measures.  Com- 
plete removal  of  the  tumor  by  resection  of  the  pylorus  will  be  possi- 
ble only  when  the  carcinoma  is  not  too  extensive  and  is  not  bound 
by  adhesions  to  adjacent  organs,  and  has  not  yet  given  rise  to 
metastases  in  other  viscera,  particularly  not  in  the  adjacent  lym- 
phatic glands.  AVhen  signs  of  pyloric  stenosis  are  present  and 
resection  of  the  pylorus  is  not  possible,  gastro-enterostomy  should 
be  effected ;  that  is,  the  stomach  should  be  sutured  to  a  loop  of 
small  intestine,  and  at  this  point  the  lumen  of  the  stomach  and 
the  bowel  should  be  made  continuous  by  means  of  an  orifice  of 


DILATATION  OF  THE  STOMACH  227 

communication.  In  cases  of  carcinoma  of  the  cardia  gastrostomy 
may  be  attempted  if  the  cardia  is  no  longer  permeable  for  food 
and  drink,  but  this  operation  has  not  yet  yielded  brilliant  results. 
Internal  treatment  can  only  be  purely  symptomatic.  The  most 
important  matter  is  that  of  diet.  Such  food  should  be  prescribed 
as  makes  the  smallest  possible  demands  upon  the  digestive  activity 
of  the  stomach ;  as,  for  instance,  milk,  milk  with  coffee,  milk 
with  tea,  beef-soup  Avith  addition  of  peptone,  milk  with  soraatose, 
wine,  old  beer,  rice-pap,  mashed  potatoes,  etc.  Wine  of  con- 
durango  may  be  prescribed  to  stimulate  the  appetite  : 

R  Wine  of  condurango,  200.0  (6J  fluidounces). 

Dose :  15  c.c.  (1  tablespoonful)  thrice  daily. 

The  use  of  dilute  hydrochloric  acid  (10  drops  in  a  wine-glassful  of 
tepid  water  30  minutes  after  the  midday  and  the  evening  meal) 
may  be  recommended.  Morphin  hydrochlorate  will  be  required 
for  the  severe  pain,  although  this  should  be  prescribed  only  when 
absolutely  necessary,  as  experience  has  shown  that  the  dose  must 
be  progressively  increased,  as  a  result  of  which  certain  dangers 
may  arise.  Great  relief  is  often  afforded  by  systematic  irrigation 
of  the  stomach,  and  under  such  treatment  the  bodily  weight  is 
frequently  observed  to  increase  considerably  within  a  short  time. 
By  this  means  the  stomach  is  freed  from  the  stagnating  remnants 
of  food  and  also  from  toxic  substances.  From  a  diagnostic  point  of 
view  it  is  further  important  to  examine  the  irrigation-fluid  for  the 
presence  of  flakes  that,  upon  microscopic  examination,  may  prove 
to  be  carcinomatous  tissue. 


DILATATION  OF  THE  STOMACH   (GASTRECTASIS) . 

!]^tiology. — Dilatation  of  the  stomach  consists  primarily  in 
an  acquired  increase  in  the  capacity  of  the  stomach,  although  this 
is  almost  always  invariably  associated  with  stasis  and  fermentation  of 
the  gastric  contents,  so  that  the  latter  process  must  also  be  included  in 
the  clinical  conception  of  gastrectasis.  The  most  common  cause  for 
dilatation  of  the  stomach  is  stenosis  of  the  pylorus,  and  this  is  often 
due  to  cicatrized  ulcers.  Carcinoma  of  the  pylorus  may  also  give 
rise  to  stenosis  of  this  orifice.  Benign  hypertrophy  of  the  pyloric 
ring  occurs  less  commonly,  and  obstruction  of  the  pylorus  by  for- 
eign bodies  or  gastric  polypi  still  less  commonly.  At  times  the 
pylorus  is  obstructed  by  pressure  or  traction  from  without,  as,  for 
instance,  by  new-growths  of  the  intestine,  the  omentum,  the  liver, 
or  the  kidneys,  by  wandering  kidney,  and  the  like.  It  will  be 
easily  understood  that  stenosis  of  the  pylorus  may  readily  give  rise 
to  gastrectasis,  for  if  the  food  stagnates  in  the  stomach  it  causes 
stretching  of  this  viscus  by  reason  of  its  weight,  and  in  addition 
there  is  the  influence  of  fermentation  of  the  gastric  contents. 


228  DIGESTIVE  ORGANS 

Also,  in  the  absence  of  pyloric  stenosis  long-continued  over-filling 
of  the  stomach  with  food  may  give  rise  to  gastric  dilatation.  This 
condition  is  observed  in  gourmands  and  in  diabetics,  in  whom  the 
appetite  is  morbidly  increased.  The  filling  of  the  stomach  with 
indigestible  articles  is  also  dangerous.  For  this  reason  conjurers 
suffer  from  gastrectasis  in  consequence  of  the  practice  of  swallow- 
ing stones  and  other  indigestible  articles  for  the  purpose  of  sus- 
staining  their  supernatural  powers.  Finally,  dilatation  of  the 
stomach  is  frequently  a  sequel  of  diseases  of  the  wall  of  the  stom- 
ach, as,  for  instance,  chronic  gastric  catarrh.  Gastrectasis  has  been 
observed  also  in  connection  with  extensive  ulceration  of  the  stomach. 
At  times  nervous  influences  are  operative  by  causing  diminution  in 
the  tone  of  the  gastric  musculature.  Anemic,  nervous,  and  debili- 
tated individuals  (as,  for  instance,  tuberculous  patients),  therefore, 
not  rarely  suffer  from  gastrectasis.  It  is  noteworthy  that  perigastric 
adhesions  may  give  rise  to  dilatation  of  the  stomach.  Gastrectasis 
is  a  most  common  disorder,  which  may  appear  even  in  children. 
Naturally  it  is  often  diagnosed  Avhen  it  does  not  exist,  even  by 
so-called  "  stomach-specialists,"  Avho  do  not  deem  it  necessary  to 
determine  accurately  the  size  of  the  stomach  in  every  case. 

Anatomic  Alterations. — Dilatation  of  the  stomach  is  char- 
acterized principally  by  the  increased  size  of  the  viscus,  the  enlarge- 
ment taking  place  in  all  directions.  Upon  opening  the  abdomen 
in  advanced  cases  scarcely  anything  but  the  stomach  comes  into 
view,  with  its  lesser  curvature  at  the  level  of  the  ensiform  carti- 
lage and  its  greater  curvature  projecting  into  the  true  pelvis. 
Usually  the  enlarged  organ  contains  a  large  amount  of  jiuid — 
at  times  more  than  20  liters  ;  and  if  the  wall  of  the  stomach  be 
palpated,  not  rarely  the  fluid  can  be  observed  to  fluctuate  to  and 
fro.  The  mucous  membrane  of  the  stomach  usually  exhibits  signs 
of  a  chronic  catarrhal  condition.  The  walls  of  the  stomach  at 
times  present  great  thickening,  especially  of  the  muscular  layer, 
which  is  often  traversed  by  broad  bands  of  connective  tissue ; 
at  other  times  the  walls  of  the  stomach  are  unusually  thin. 
Increased  thickness  of  the  walls  of  the  stomach  may  be  expected, 
particularly  in  association  with  stenosis  of  the  pylorus,  to  a  cer- 
tain degree  in  the  nature  of  compensatory  muscular  hypertrophy, 
while  thinning  attends  conditions  of  general  debility.  A  distinc- 
tion has  accordingly  been  made  between  hypertrophic  and  atrophic 
gastrectasis. 

Symptoms  and  Diagnosis. — In  order  to  demonstrate  dila- 
tation of  the  stomach  the  most  convenient  and  most  reliable  method 
consists  in  distending  the  viscus  artificially  by  means  of  carbon 
dioxid.  For  this  purpose  1  or  2  teaspoonfuls  of  tartaric  acid 
dissolved  in  a  wine-glassful  of  water  are  swallowed,  and  immedi- 
ately afterward  a  like  amount  of  water  containing  1  or  2  teaspoon- 
fuls of  sodium  bicarbonate  in  solution.     After  the  lapse  of  a  few 


DILATATION  OF  THE  STOMACH  229 

seconds  the  outlines  of  the  stomach  often  become  visible  beneath 
the  abdominal  walls.  On  percussion  or  palpation  with  flexed 
fingers  a  sense  of  resistance  like  that  yielded  by  an  air-cushion 
will  be  perceived,  which  disappears  below  the  greater  curvature 
of  the  stomach.  On  percussion  over  the  stomach  a  deep-tympanitic 
note  is  yielded,  and  on  auscultation  not  rarely  small  moist  rales 
are  audible  in  the  course  of  the  greater  curvature,  resulting  from 
ebullition  of  the  carbon  clioxid. 

The  distinctive  feature  of  dilatation  of  the  stomach  consists  in 
the  uniform  enlargement  of  the  viscus.  The  greater  curvature  is 
not,  as  in  health,  situated  above  the  umbilicus,  but  it  is  displaced 
for  a  greater  or  lesser  distance  below.  Toward  the  left  the  stomach 
extends  beyond  the  left  anterior  axillary  line,  and  toward  the 
right  beyond  the  right  parasternal  line.  Often  the.  lesser  cur- 
vature of  the  stomach,  which  in  health  is  concealed  by  the  liver, 
is  displaced  unduly  downward,  and  is  distinctly  appreciable  to 
the  eye. 

Displacement  downward  of  the  greater  curvature  of  the  stomach  below 
the  umbilicus,  without  displacement  of  the  lateral  boundaries  of  the  stomach 
to  the  right  and  to  the  left,  is  not  indicative  of  dilatation  of  the  stomach, 
for  such  a  condition  may  be  due  to  displacement  downward  of  the  stomach  as 
a  whole — gastroptosis.  Even  a  stomach  enlarged  in  all  directions  is  not  neces- 
sarily to  be  considered  as  abnormally  dilated,  but  the  condition  may  be 
congenital — so-called  megalogasfria.  In  contradistinction  from  dilatation 
of  the  stomach,  the  functional  activity  of  the  organ  is  unimpaired  when 
megalogastria  exists. 

In  consequence  of  fermentative  decomposition  of  the  contents 
of  the  stomach  the  viscus  is  often  so  greatly  distended  with  gas 
that  its  boundaries  can  be  made  out  by  inspection,  palpation,  and 
percussion,  without  artificial  distention  by  means  of  carbon  dioxid. 
If  dilatation  of  the  stomach  be  dependent  upon  pyloric  constric- 
tion, active  muscular  waves  may  frequently  be  seen  to  pass  from 
the  cardia  to  the  pylorus  beneath  the  abdominal  wall.  At  times 
bubbles  of  gas  can  be  heard  arising  from  the  fermenting  gastric 
contents.  If  the  stomach  be  vigorously  agitated,  loud  splashing 
sounds  frequently  occur,  which  some  patients  can  induce  by  rapidly 
rising  upon  the  feet,  or  by  rapidly  rolling  from  one  side  of  the 
body  to  the  other.  These  murmurs  occur  with  especial  frequency 
and  loudness  in  association  with  dilatation  of  the  stomach,  but  they 
appear  also  under  all  conditions  in  which  the  stomach  contains  at 
the  same  time  both  gas  and  liquid.  At  most  it  is  distinctive  of 
dilatation  of  the  stomach  that  these  sounds  are  appreciable  when 
the  abdominal  wall  below  the  umbilicus  is  suddenly  jarred. 
With  the  physical  alterations  thus  far  described  in  cases  of  gas- 
tric dilatation  manifestations  indicative  of  deranged  functional 
activity  of  the  stomach  are  constantly  associated.  A  peculiar 
variety  of  vomiting  occurs  with  especial  frequency.  The  patient 
may  not  vomit  at  all  for  several  days  in  succession,  but  when 


230  DIGESTIVE  ORGANS 

vomiting  occurs  such  enormous  masses  are  expelled  that  the 
amount  of  vomited  matter  alone  is  indicative  of  dilatation  of  the 
stomach.  The  vomited  mattei-  is  generally  conspicuous  for  its 
markedly  rancid  or  penetrating  acid  odor.  If  it  be  permitted  to 
stand  in  a  vessel  in  a  warm  room,  it  frequently  continues  to 
undergo  fermentation,  and  eventually  frothy  matter  may  over- 
flow the  margin  of  the  receptacle.  Microscopic  examination  dis- 
closes, in  addition  to  particles  of  food  and  bacteria,  especially 
oblong  yeast-cells,  and  layers  of  sarcinse,  at  times  also  molds 
(Fig.  26).  The  vomitus  is  usually  characterized  by  a  highly  acid 
reaction,  although  often  it  contains  no  free  hydrochloric  acid, 
"svhereas  in  consequence  of  fermentation  of  carbohydrates  it  con- 
tains  an   abundance    of  lactic,  acetic,  and   butyric   acids.     The 


Fig.  26. — Yeast-cells  and  sarcinse  from  the  vomitus  in  a  case  of  gastric  dilatation ;  magni- 
fied 275  times  (personal  observation,  Zurich  clinic). 

patient  often  complains  of  an  acid,  almost  burning,  taste  on  the 
part  of  the  vomited  matter,  and  the  teeth  are  set  on  edge.  Patients 
are  frequently  annoyed  by  eructation — singultus.  After  both 
vomiting  and  also  eructation  a  burning,  boring  sensation  not 
rarely  remains  behind  the  sternum — heart-burn,  jyyrosis. 

Eructation  of  combustible  gases  has  been  observed  on  a  number  of  occa- 
sions, and  is  at  times  first  noticed  by  patients  on  lighting  a  cigar.  Analy- 
sis has  shown  that  these  gases  consist,  in  addition  to  oxygen,  nitrogen, 
hydrogen,  and  carbon  dioxid,  also  of  marsh-gas,  carbon  monoxid,  oil-form- 
ing gas,  and  hydrogen  siilphid. 

The  functions  of  the  stomach  are  greatly  altered  in  cases  of 
gastric  dilatation.  The  period  required  for  the  absorption  of 
potassium  iodid  is  prolonged  (more  than  fifteen  minutes).  The 
motor  activity  of  the  stomach  also  has  suffered  considerable  im- 
pairment. Free  hydrochloric  acid  is  frequently  wanting  in  the 
gastric  contents.     The  appetite  at  times  suffers,  as,  for  instance, 


DILATATION  OF  THE  STOMACH  231 

in  -cases  of  carcinomatous  stenosis  of  the  pylorus.  In  other  in- 
stances, on  the  contrary,  the  appetite  is  excessive,  because  but 
little  of  the  food  ingested  is  absorbed.  There  is  almost  always 
marked  increase  in  thirst,  as  fluids  likewise  are  absorbed  only 
with  difficulty  by  a  dilated  stomach,  and  also  are  but  inadequately 
propelled  into  the  intestinal  canal.  The  tongue  is  frequently 
marked  by  unusual  redness  and  cleanness,  because  it  is  irritated 
and  cleaned  by  the  highly  acid  vomited  matters.  The  urine  is 
usually  passed  in  small  amount.  After  abundant  acid  vomiting 
it  not  rarely  yields  an  alkaline  reaction,  and  a  peculiar  sediment, 
which,  in  addition  to  coffin-lid  crystals  of  amraonio-magnesium 
phosphate,  consists  of  rhombic  plates  of  magnesium  phosphate. 
The  boioels  are  generally  constipated.  The  general  nutrition 
suffers  in  marked  degree.  The  patients  undergo  great  emacia- 
tion ;  their  muscles  become  flabby,  the  skin  thin  like  tissue-paper 
and  deficient  in  fat,  the  face  wrinkled,  and  the  complexion  ashy 
gray  or  grayish'  yellow.  Some  patients  present  an  almost  desic- 
cated, mummy-like  appearance.  If  the  nutritive  disturbance 
cannot  be  checked,  death  may  result  from  progressive  asthenia. 

In  some  cases  dilatation  of  the  stomach  is  attended  with  pecu- 
liar complications,  which  have  been  attributed  to  auto-intoxication, 
upon  the  assumption  that  certain  putrefactive  alkaloids  or  pto- 
mains  have  developed  in  the  stomach,  which  exert  an  influence 
upon  the  nervous  system  especially.  Under  such  conditions 
symptoms  of  tetany  appear.  This  complication  is  not  unattended 
with  danger,  and  may  be  the  immediate  cause  of  death. 

The  duration  of  dilatation  of  the  stomach  will  depend  upon  the 
fact  whether  the  patients  observe  strict  dietetic  precautions  or  not. 
If  they  will  obey  appropriate  medical  advice,  the  disease  may 
exist  for  decades,  and  be  tolerated  without  serious  discomfort. 
The  course  of  events  is  often  sucli  that  periods  of  aggravation 
and  of  improvement  alternate  accordingly  as  the  mode  of  life  is 
careful  or  indifferent. 

Prognosis. — The  prognosis  of  dilatation  of  the  stomach 
depends,  in  the  first  place,  upon  the  causative  factors.  It  is  from 
the  outset  unfavorable  in  cases  of  carcinomatous  stenosis  of  the 
pylorus,  for  instance.  If  the  condition  is  not  dependent  upon 
some  disorder  in  itself  dangerous  to  life,  not  only  relief,  but  even 
cure,  may  be  effected. 

Treatment. — Dilatation  of  the  stomach  requires  both  causal 
and  dietetic  treatment.  If  the  condition  is  dependent  upon  ste- 
nosis of  the  pylorus,  an  attem])t  should  be  made  to  correct  this, 
and  surgical  measures  will  probably  always  be  required  for  the 
purpose,  as,  for  instance,  resection  of  the  pylorus — pyloroplasty, 
or  bloodless  dilatation  of  the  pyloric  ring.  If  the  obstruction  be 
irremediable,  brilliant  results  are  often  attained  by  gastro-enter- 
ostomy ;  that  is,  the  establishment  of  an  artificial  communication 


232  DIGESTIVE  ORGANS 

between  tlie  stoniacli  and  tlic  bowel,  and  tluis  avoiding  the  pylorus. 
The  sugi^estion  of  Jiireher,  to  eorreet  dilatation  of  the  stonuicli  by 
making  a  fold  in  the  viscus,  appears  as  yet  to  have  been  acted 
upon  in  but  few  instances.  Kspecially  good  results  may  be 
attained  by  systematic  siphonage  of  the  stomach,  in  order  to  free 
the  viseus  from  its  excessive  contents,  and  to  afford  it  opportunity 
gradually  to  contract  to  its  natural  size. 


Fig.  27. — Stomach-siphon  of  soft  rubber. 

As  a  stomach-siplion  a  soft  stomach-tube  may  be  employed,  and  this  is 
connected  by  a  glass  tube  with  a  rubber  tube  1  meter  long.  Into  the  free 
end  of  the  rubber  tube  a  glass  funnel  is  introduced  (Fig.  27).  The  stomach- 
tube  is  introduced  as  far  as  possible  into  the  stomach,  while  the  patient 
makes  efforts  at  swallowing,  and  the  warm  water  is  permitted  to  flow  into 
the  funnel  until  the  patient  complains  of  a  sense  of  fulness  or  no  more 
water  will  enter.  Tbe  rubber  tube  is  then  compressed  between  the  fingers 
and  the  funnel  is  inverted  downward  into  a  vessel.  If  the  pressure  upon 
the  tube  be  now  relaxed,  the  water  that  has  been  introduced,  together  with 
the  contents  of  the  stomach,  will  escape.  This  procedure  is  repeated  until 
the  irrigating  fluid  returns  perfectly  clear.  At  times  the  discharge  is  pre- 
vented by  obstruction  of  the  fenestra  of  the  tube  by  coarse  particles  of  food, 
as,  for  instance,  pieces  of  meat.  Usually  the  obstruction  can  be  overcome 
by  strong  pressure  with  the  hand  upon  the  tube  or  by  the  introduction  of 
water  into  the  funnel.  Otherwise  the  tube  nuist  be  removed  and  the  lumen 
made  clear.  If  the  patient  complain  of  marked  acidity,  it  is  well  at  the 
conclusion  of  the  procedure  to  wash  the  stomach  with  artificial  Carlsbad 
salt  (one  teaspoonful  to  a  quart  of  tepid  water).  In  order  to  prevent  fer- 
mentation of  food  in  the  stomach,  irrigation  with  dkinfrofanis  has  also  been 
practised.  It  is  important  to  determine  by  means  of  graduates  the  amount 
of  water  introduced,  and  also  that  which  escapes,  for  only  if  the  latter  be 
greater  than  the  former  can  there  be  certainty  that  the  contents  of  the 
stomach  have  been  removed.  Under  the  opposite  conditions  there  is 
danger  that  the  stomacii  would  be  more  greatly  overloaded.  At  first  the 
irrigations  are  practised  daily,  and  we  make  them,  not,  as  some  have  advised, 


DISPLACEMENTS  OF  THE  STOMACH  233 

in  the  evening,  but  in  the  morning.  Gradually  one,  then  two,  and  finally 
several  days  are  permitted  to  intervene.  Patients  learn  how  to  irrigate  the 
stomach  in  a  short  time,  as  a  rule,  and  intelligent  patients  may  be  permitted 
without  concern  to  jn-actise  the  irrigation  at  home.  Should  signs  of  aggra- 
vation appear,  the  irrigation  must  again  be  practised  with  greater  frequency. 
Most  patients  usually  feel  so  much  improved  after  the  first  irrigation  that 
they  can  scarcely  await  the  time  for  the  next.  The  favorable  influence  of 
the  procedure  also  becomes  clearly  appreciable  in  their  appearance.  The 
dull  aspect  again  becomes  fresher  and  animated.  Bodily  weight  and  vigor 
often  increase  with  remarkable  rai^idity,  and  the  complexion  acquires  a 
healthy  color.  Disagreeable  accidents  but  rarely  occur  in  connection  with 
irrigation  of  the  stomach.  At  times  tetany  has  been  observed  to  follow 
directly  upon  the  manipulation,  probably  in  consequence  of  the  mechanical 
irritation  of  the  stomach. 

At  the  conclusion  of  the  irrigation  it  is  well  for  the  patients  to 
remain  in  bed  for  one  or  two  hours,  and  to  apply  an  ice-bag  to  the 
epigastrium  in  order  to  improve  the  tone  of  the  musculature  of 
the  stomach.  It  may  also  be  advantageous  to  practise  massage  of 
the  epigastrium,  or  to  apply  the  faradic  current,  or  to  inject  strych- 
nin subcutaneously  (0.1  :  10;  0.3 — 4  minims). 

Individuals  in  wliom  dilatation  of  the  stomach  has  developed 
in  consequence  of  over- eating  should  be  provided  with  a  rigid 
diet-list,  so  as  to  avoid  overloading  of  the  stomach  in  the  future. 
In  cases  in  anemic  and  nervous  individuals  preparations  of  iron, 
courses  of  cold-water  treatment,  and  the  like,  are  indicated.  Relax- 
ation of  the  abdominal  walls  requires  the  use  of  an  abdominal 
binder.  The  dietetic  regulations  are  the  same  in  all  varieties  of 
dilatation  of  the  stomach.  Carbohydrates  are  to  be  avoided  as 
strictly  as  possible,  on  account  of  the  readiness  with  which  they 
undergo  decomposition.  The  ingestion  of  liquids  should  also  be 
restricted.  Patients  should  confine  themselves  especially  to  an 
animal  diet,  and  the  intervals  between  meals  should  not  be  too 
long.  In  order  to  relieve  the  stomach  of  catarrhal  conditions  of 
the  mucous  membrane  that  may  be  present,  courses  of  treatment  at 
springs  are  often  of  great  utility,  and  particularly  such  as  are  fol- 
lowed at  Carlsbad  have  yielded  brilliant  results. 

DISPLACEMENTS  OF  THE  STOMACH  (DYSTOPIA 
VENTRICULIj. 

Displacements  of  the  stomach  are  either  acquired  or  congenital. 
Congenital  displacement  of  the  stomach  occurs  in  connection  with 
transposition  of  the  viscera,  when  other  organs  are  likewise  dis- 
placed, so  that,  for  instance,  the  heart  may  be  situated  on  the  right 
side  of  the  thorax,  the  liver  in  the  left  hypochondrium,  the  spleen 
in  the  right,  etc.  Under  such  circumstances  the  cardia  will  be 
found  upon  the  right  and  the  pylorus  upon  the  left  side.  This 
condition  is  unattended  Avith  other  disturbances.  Acquired  dis- 
placement of  the  stomach  is  also  known  as  gastro^jtosis.     Attention 


234  DIGESTIVE  ORGANS 

has  only  of  late  been  directed  to  the  frequency  of  this  occurrence. 
The  condition  is  with  especial  frequency  characterized  by  an 
abnormal  depression  of  the  stomach,  so  that  when  the  viscus  is 
distended  with  carbon  dioxid  the  greater  curvature  will  be  found 
below  the  level  of  the  uml)ilicus,  while  the  transverse  area  appears 
rather  diminished.  There  is  often  besides  a  wandering  kidney  on 
the  right  side,  and  the  impression  is  created  that  both  conditioxis 
are  dependent  upon  the  same  cause,  which  most  frequently  consists 
in  the  pressure  of  constricting  clothing.  In  addition,  derange- 
ment in  the  functional  activity  of  the  stomach  occurs,  and  with 
especial  frequency  anacidity  of  the  gastric  juice  and  motor  weak- 
ness. The  patients  often  complain  of  a  sense  of  pressure  or  of  pain 
in  the  epigastrium,  of  loss  of  appetite,  eructation,  and  even  vom- 
iting. The  wearing  of  constricting  clothing  should  be  interdicted 
and  appropriate  diet  directed,  and,  in  the  presence  of  anacidity  of 
the  gastric  juice,  dilute  hydrochloric  acid  prescribed. 

GASTRIC  NEUROSES. 

Such  disorders  of  gastric  activity  as  are  not  attended  with 
anatomic  alterations  in  the  wall  of  the  stomach,  but  with  morbid 
activity  of  the  gastric  nervous  siqyply,  are  designated  gastric  neu- 
roses. A  distinction  is  made  between  motor,  sensory,  secretory,  and 
mixed  gastric  neuroses,  accordingly  as  the  one  or  the  other  nerve- 
path  is  involved.  At  times  the  functional  activity  of  the  nerves 
is  morbidly  increased,  at  times  diminislied. 

MOTOR  GASTRIC  NEUROSES. 

NERVOUS  VOMITING. 

Symptoms,  Diagnosis,  and  Prognosis. — As  the  name  of 
the  disorder  indicates,  nervous  vomiting  is  characterized  by  more  or 
less  frequent  emesis.  This  may  be  so  abundant  and  occur  with 
such  constancy  after  each  meal  that  the  nutrition  of  the  patient 
may  become  impaired  to  an  alarming  degree,  with  the  possibility 
of  starvation.  In  other  instances  the  vomiting  occurs  only  at 
certain  times  and  transitorily.  In  contradistinction  from  the  vom- 
iting that  occurs  in  connection  with  demonstrable  anatomic  disease 
of  the  stomach,  it  is  peculiar  to  nervous  vomiting  that  it  usually 
takes  place  without  preceding  nausea,  and  that  the  matters  ejected 
consist  of  the  unaltered  and  unfermented  contents  of  the  stomach. 
The  duration  of  the  affection  varies,  and,  together  with  the  prog- 
nosis, is  dependent  upon  whether  the  causative  conditions  can  be 
removed  or  not. 

etiology. — Xervous  vomiting  is  not  rarely  due  to  diseases 
of  the  brain  and  the  spinal  cord  (concussion  of  the  brain,  cerebral 
tumor,  abscess  of  the  brain,  cerebral  hemorrhage,  parasites,  cere- 


GASTRIC  NEUROSES  235 

bral  meningitis,  tabes  dorsalis,  etc.).  It  has  been  observed  also 
in  association  with  central  neuroses,  and  with  especial  frequency 
with  hysteria.  Often  nervous  vomiting  is  of  reflex  origin.  The 
best-known  instance  of  this  kind  is  the  vomiting  of  pregnancy. 
Frequently  nervous  vomiting  attends  biliary  and  renal  calculi. 
Irritative  conditions  in  the  most  diverse  organs  may,  however, 
also  give  rise  to  nervous  vomiting.  Vomiting  dependent  upon 
toxic  influences  may  likewise  be  considered  of  nervous  origin.  This 
may  be  induced  intentionally  by  certain  remedies  (emetics,  such 
as  ipecacuanha-root,  tartar  emetic,  copper  sulphate,  apomorphin 
hydrochl orate) ;  or  it  may  be  due  to  certain  poisons  generated 
within  the  body  itself  as  a  result  of  metabolic  processes  (auto- 
intoxication), as,  for  instance,  in  uremia  and  cholemia.  Nervous 
vomiting  occurs  most  commonly,  in  icomen,  because  it  is  often 
dependent  upon  disease  of  the  uterus  and  its  appendages.  It  is 
less  commonly  encountered  in  children  than  in  adults,  as  many 
of  the  causative  conditions  are  observed  only  in  the  latter. 

Treatment. — Nervous  vomiting  requires,  in  the  first  place, 
causal  treatment.  Symptomatically,  sulphuric  ether  (5  drops  on 
sugar  repeatedly),  ethereal  tincture  of  valerian  (25  drops  thrice 
daily),  tincture  of  iodin  (1.0  :  200  ;  15  c.c. — 1  tablespoonful — every 
two  hours),  and  morphin  hydrochlorate  (subcutaneously)  are  indi- 
cated.    The  swallowing  of  small  bits  of  ice  is  also  advisable. 

NERVOUS  ERUCTATION. 

J^ervous  eructation  occurs  especially  in  cases  of  hysteria,  neuras- 
thenia, and  hypochondriasis.  The  patients  suffer  from  eructation 
of  gas  that  they  have  swallowed  a  short  time  previously  and  often 
expel  with  a  loud,  belching  sound.  At  times  the  condition  may 
persist  for  hours  or  even  days,  or  it  may  occur  in  paroxysms  in 
consequence  of  psychic  disturbances.  Sometimes  an  attack  can 
be  induced  by  pressure  upon  certain  parts  of  the  body.  The  dis- 
order is  unattended  with  danger. 

The  treatment  should  be  partly  psychic  and  in  part  directed 
against  the  primary  affection. 

NERVOUS  REGURGITATION. 

Regurgitation  of  food  is  a  phenomenon  that  occurs  also  in 
healthy  persons  when  the  stomach  is  irritated  by  the  ingestion 
of  an  excess  of  food  or  of  food  that  is  too  cold  or  too  hot,  or  by 
too  rapid  eating  and  insufficiently  masticated  food.  The  condition 
may  be  morbidly  exaggerated  in  cases  of  hysteria,  neurasthenia, 
and  hypochondriasis.  If  fermentative  processes  in  the  stomach  are 
superadded,  the  regurgitated  matters  may  have  an  acid  or  a  rancid 
taste.  Regulation  of  the  diet,  the  cooperation  of  the  patient  in  an 
effort  to  suppress  the  regurgitation,  and  treatment  of  the  primary 
disorder  are  capable  of  correcting  the  condition. 


236  DIGESTIVE  ORGANS 

PERISTALTIC   UNREST   OF  THE   STOMACH   (NERVOUS  TORMINA  OF 
THE  STOMACH). 

Nervous  and  neurasthenic  individmils  complain  at  times  of  a 
disagreeable  feeling  in  the  stomach  and  of  restless  movements  in  the 
epigastrium,  which  not  rarely  set  in  during  the  evening  and  even 
during  the  night,  and  disturb  sleep.  These  manifestations  are 
frequently  associated  with  visible  active  contractions  of  the  mus- 
culature of  the  stomach,  and  peristaltic  movements  may  be  ob- 
served passing  slowly  from  the  cardia  to  the  pylorus.  Care  must 
be  taken  to  avoid  confounding  the  condition  with  the  active 
movements  of  the  stomach  that  occur  in  the  presence  of  pyloric 
stenosis  in  the  endeavor  to  overcome  the  obstruction  to  the  passage 
of  the  chyme  from  the  stomach  into  the  duodenum.  The  absence 
of  the  causes  and  of  the  alterations  of  stenosis  in  the  pyloric  region, 
and  the  normal  character  of  gastric  digestion  in  other  respects,  are 
indicative  of  nervous  unrest  of  the  stomach. 

Treatment  should  be  directed  against  the  primary  disorder. 
In  addition,  the  diet  should  be  regulated.  Rest  in  bed  and  hot 
cataplasms  should  further  be  advised. 

HYPERMOTILITY  OF  THE  STOMACH. 

Hypermotility  of  the  stomach  may  be  recognized  from  the 
fact  that  after  a  meal  of  meat  the  stomach  is  empty  in  a  short 
while^  at  times  as  early  as  an  hour.  The  patients  complain  of 
excessive  appetite. 

TONIC  SPASM  OF  THE  MUSCULATURE  OF  THE  STOMACH. 

Spasm  of  the  cardia — cardiospasm — prevents  the  unobstructed 
entrance  of  food  into  the  stomach.  The  stomach-tube  also  en- 
coimters  resistance  at  the  cardia — thus  at  40  cm.  (lof  inches)  beyond 
the  margin  of  the  teeth ;  but  this  frequently  yields,  in  contradis- 
tinction from  organic  stenosis  of  the  cardia,  if  the  sound  be  per- 
mitted to  remain  quietly  for  a  few  seconds.  The  disorder  occurs 
in  nervous  ])ersons,  but  may  also  be  induced  by  reflex  influences 
in  connection  with  some  diseases  of  the  stomach,  as,  for  instance, 
gastric  ulcer. 

Spasm  of  the  pylorus  causes  obstruction  to  the  passage  of  food 
from  the  stomach  into  the  intestine,  and  may  be  readily  confounded 
with  organic  stenosis  of  the  pylorus.  At  times  there  is  spasm 
simultaneously  at  the  pylorus  and  at  the  cardia.  Under  such  con- 
ditions marked  distention  of  the  stomach  with  gas  may  take  place, 
and  this  may  give  rise  to  disagreeable  sensations  in  the  epigastrium 
and  to  conditions  of  dyspnea — so-called  dyspeptic  asthma.  The 
distinctive  feature  of  pure  nervous  pyloric  stenosis  is  the  parox- 
ysmal ocrurrcnec  of  the  phenonicua  mentioned. 

Tonic  spasm  of  the  entire  stomach  occurs  in  connection  with 
pyloric  stenosis,  and  also  as  an  independent  neurosis.     The  stom- 


GASTRIC  NEUROSES  237 

ach  appears  contracted  with  board-like  hardness.  Often  painful 
sensations  in  the  epigastrium  are  appreciable  during  the  spasmodic 
attack. 

All  spasmodic  conditions  of  the  stomach  should  be  treated 
by  dietetic  measures,  hot  cataplasms,  bromids,  or  injections  of 
morphin.     Besides,  the  primary  disorder  should  be  relieved. 

INSUFFICIENCY  OR  INCONTINENCE  OF  THE  PYLORUS. 

Insufficiency  of  the  pylorus  is  characterized,  on  generation  of 
carbon  dioxid  in  the  stomach,  by  failure  of  distention  to  take 
place  or  by  its  transitory  occurrence ;  whereas  protrusion  of  the 
entire  abdomen  occurs  because  the  gas  has  passed  into  the 
intestine  from  the  stomach  through  the  inefficient  pylorus.  The 
condition  is  encountered  in  cases  of  hysteria,  neurasthenia,  and 
spinal  softening,  and  as  a  purely  nervous  disorder,  although  it 
may  result  in  connection  with  severe  gastric  catarrh  and  destruc- 
tion of  the  pyloric  sphincter  by  ulceration  or  carcinoma.  Physio- 
logically incontinence  of  the  pylorus  is  believed  to  be  present 
when  the  stomach  is  empty. 

The  treatment  should  be  directed  against  the  primary  dis- 
order. 

RUMINATION  (MERYCISM). 

Individuals  who  practise  rumination  return  the  food  from  the 
stomach  into  the  mouth  a  sliort  time  after  its  ingestion,  often  re- 
chewing  it  with  great  satisfaction,  and  many  experiencing  a  more 
agreeable  sensation  than  when  the  food  was  originally  ingested. 
Some  patients  repeat  the  practice  after  each  meal ;  others  only  when 
they  eat  hastily  and  do  not  masticate  the  food  sufficiently.  The 
nutrition  may  remain  unchanged;  and  only  when,  in  consequence  of 
gastric  catarrh  or  dilatation  of  the  stomach,  decomposition  of  the 
food  takes  place,  and  the  patients,  by  reason  of  the  disagreeable 
taste  of  the  food,  eject  the  regurgitated  material,  do  emaciation  and 
anemia  occur.  The  functional  activity  of  the  stomach  varies,  and 
at  times  anacidity  and  at  other  times  hyperacidity  of  the  gastric 
juice  have  been  observed.  Rumination  is  a  much  more  common 
disorder  than  is  generally  believed.  I  have  quite  accidentally 
detected  a  number  of  persons  engaged  in  rumination  who  from  a 
sense  of  shame  were  cleverly  able  to  conceal  the  unpleasant  prac- 
tice. Among  the  causative  factors  nervous  diseases  must  be  con- 
sidered, as,  for  instance,  chorea,  epilepsy,  and  idiocy.  Individuals 
suffering  from  pulmonary  tuberculosis  not  rarely  practise  rumina- 
tion. Imitation  is  an  important  etiologic  factor.  Dietetic  errors 
are  often  operative,  particularly  too  hurried  eating  and  insufficient 
mastication  of  the  food.  At  times  rumination  develops  in  the 
course  of  diseases  of  the  stomach  and  the  intestines  (a  blow  upon  the 
stomach,  constipation).  Patients  frequently  state  that  the  disorder 
has  begun  with  eructation,  that  subsequently  they  acquired  the 


238  DIGESTIVE  ORGANS 

ability  of  inducing  the  eructation  intentionally,  and  that  finally 
they  became  ruminants,  the  contents  of  the  stomach  being  forced 
into  the  mouth  unconsciously.  Many  are  able  to  suppress  the 
practice  voluntarily.  Anatomic  alterations  of  a  distinctive  char- 
acter are  unknown.  The  presence  of  dilatation  at  the  cardia,  con- 
stituting a  so-called  fore-stomach,  is  an  accidental  and  rare  condi- 
tion. For  the  development  of  rumination  weakness  of  the  mus- 
culature at  the  cardia  is  probably  necessary,  as  otherwise  the  food 
could  not  be  returned. 

In  the  treatment  the  cooperation  of  the  patient  and  his  will- 
ingness to  suppress  the  practice  are  the  most  important  factors. 
Some  persons,  however,  are  unwilling  to  be  deprived  of  the 
pleasure  afforded  by  rumination.  It  is  important,  further,  that 
the  food  should  be  eaten  slowly,  and  be  thoroughly  masticated. 
At  times  rumination  can  be  prevented  by  the  swallowing  of  bits 
of  ice.  Besides,  nervines,  as,  for  instance,  bromids,  should  be 
employed. 

ATONY  OF  THE  STOMACH. 

Atony  of  the  stomach  consists  in  diminution  in  the  tone  of  the 
gastric  musculature  and  in  motor  weakness.  The  condition  is 
thus  attended  with  the  danger  that  the  food  may  remain  stagnant 
in  the  stomach  for  a  long  time,  and  undergo  decomposition,  with 
the  development  of  dilatation  of  the  stomach.  The  patients  com- 
plain principally  of  a  sense  of  fulness  and  of  pressure  in  the  epi- 
gastrium. The  condition  is  frequently  encountered  in  anemic, 
del^ilitated,  nervous,  hysterical,  and  hypochondriacal  individuals. 
The  disorder  is  curable.  A  nutritious  diet,  consisting  rather  of 
solid  than  of  liquid  food,  should  be  prescribed,  and  the  general 
invigoration  of  the  body  promoted  by  cold  frictions  and  massage. 
Besides,  an  effort  should  be  made  to  correct  the  primary  disorder* 

SENSORY  NEUROSES  OF  THE  STOMACH. 

NERVOUS  GASTRALGIA. 

Symptoms  and  Diagnosis. — Nervous  gastralgia  is  often 
attended  with  intense  pain  in  the  epigastrium,  which  appears  at 
times  when  the  stomach  is  empty,  and  at  other  times  soon  after 
the  ingestion  of  food,  in  the  latter  event  particularly  Avhen  food  or 
drink  is  taken  that  is  not  well  borne  even  in  a  condition  of  health. 
Not  rarely  an  attack  of  gastralgia  has  been  preceded  by  psychic 
disturbances,  or  in  women  it  may  occur  at  the  menstrual  period. 
The  severity  of  the  pain  is  frequently  so  great  that,  in  consequence 
of  reflex  spasm  of  the  cutaneous  vessels,  the  skin  becomes  pale 
and  cool,  and  covered  with  a  clammy  sweat.  The  pulse  becomes 
small.  The  patients  moan,  and  double  themselves  up.  Syncope 
and  clonic  muscular  contractions  may  occur.  At  times  the  dis- 
ease may  terminate  with  a  single  attack  of  pain  or  after  a  small 


GASTRIC  NEUROSES  239 

number,  while  in  other  instances  it  may  persist  for  mouths  and 
years.  In  the  latter  event  several  attacks  may  occur  in  the  course 
of  a  single  day.  Examination  of  the  stomach  yields  little  infor- 
mation, and  it  is  often  difficult  to  differentiate  nervous  gastralgia 
from  that  attendant  upon  anatomic  disease  of  the  stomach,  as,  for 
instance,  round  ulcer  of  the  stomach.  It  is  noteworthy  that 
nervous  gastralgia  is  at  times  relieved  by  firm  pressure  in  the 
epigastrium,  so  that  not  rarely  during  the  attack  the  patients 
make  such  pressure  with  their  hands  or  press  the  epigastrium 
against  some  resistant  body.  If  the  ingestion  of  food  is  not 
observed  to  exert  any  influence  upon  the  occurrence  of  an  attack 
of  pain,  this  is  rather  indicative  of  nervous  gastralgia.  It  is 
further  contended,  also,  that  nervous  gastralgia  disappears  upon 
galvanization  of  the  epigastrium,  with  the  positive  pole  (anode) 
applied. 

Prognosis. — Nervous  gastralgia  is  a  most  distressing,  but 
not  a  fatal  disease.  It,  therefore,  occasions  no  concern  with 
regard  to  the  continuance  of  life. 

;^tiologfy. — The  disorder  occurs  most  commonly  in  associa- 
tion with  certain  central  neuroses,  particularly  hysteria  and  neu- 
rasthenia. Anatomically  demonstrable  disease  of  the  nervous  sys- 
tem may  also  be  attended  with  gastralgia,  as,  for  instance,  tabes 
dorsalis.  The  disorder  is  often  dependent  upon  reflex  influences. 
Women  with  disease  of  the  uterus  or  the  ovaries  especially  suffer 
not  rarely  from  nervous  gastralgia.  In  some  families  the  disease 
is  transmitted  by  heredity,  probably  because  the  morbid  condition 
of  the  nervous  system  is  inherited.  Mental  over-exertion,  wasting 
discharges,  excessive  indulgence  in  alcohol,  tea,  and  tobacco,  and 
sexual  excesses  engender  an  undeniable  predisposition  to  the  dis- 
ease. Women  are  most  commonly  attacked  because  a  large  num- 
ber of  the  causative  influences  are  operative  among  them.  Chil- 
dren are  attacked  much  less  commonly  than  adults. 

Treatment. — In  the  treatment  of  nervous  gastralgia  two 
indications  should  be  borne  in  mind :  in  the  first  place,  the  relief 
of  the  individual  attack  of  pain,  and  in  addition  the  prevention 
of  recurrence — symptomatic  and  causal  treatment.  In  the  attack 
of  pain  hot  cataplasms  may  be  applied.  If  the  pain  be  intense,  a 
subcutaneous  injection  of  morphin  should  be  given,  but  the  patient 
should  never  be  entrusted  with  a  solution  of  morphin  and  a 
syringe  for  use  at  his  discretion,  as  the  danger  of  abuse  and  of 
addiction  to  the  drug  is  too  great.  Causal  treatment  should  be 
directed  against  the  primary  disorder,  and  will  be  based  upon  the 
principles  applicable  to  the  individual  diseases. 


240  DIGESTIVE  ORGANS 

DISORDERS   OF  THE  SENSE   OF  HUNGER  AND  OF  SATIETY  (ACORIA ; 

BULIMIA;  PICA). 

Disorders  of  the  sense  of  hunger  occur,  like  most  other  gastric 
neuroses,  especially  in  cases  of  hyderia  and  neurasthenia,  and  they 
disappear,  as  a  rule,  when  the  primary  disorder  is  cured.  Acoria 
is  a  condition  in  which  the  sense  of  hunger  is  lost,  so  that  the 
patients  do  not  realize  when  they  should  take  food.  In  other 
persons  the  sense  of  satiety  is  lost,  and  they  are  exposed  to  the 
danger  of  overloading  the  stomach.  Bulimia  or  excessive  hunger 
is  characterized  by  a  morbidly  ravenous  appetite,  so  that  the 
patient  can  scarcely  await  the  usual  hour  for  meals,  and  often 
endeavors  to  suppress  the  sense  of  hunger  by  means  of  chocolate 
and  other  confections,  which  he  constantly  carries  about  with  him. 
Pica  is  an  unnatural  desire  for  unusual  and  at  times  indigestible 
articles  of  food,  as,  for  instance,  ink,  slate-pencils,  vinegar,  and 
the  like. 

SECRETORY  NEUROSES  OF  THE  STOMACH, 

HYPERCHLORHYDRIA. 

Hyperchlorhydria,  less  accurately  designated  also  hyperacidity 
or  superacidity,  indicates  an  increase  in  the  hydrochloric  acid  of 
the  gastric  juice,  so  that  the  total  acidity  of  the  gastric  contents 
after  a  trial-breakfast  may  exceed  70,  and  the  percentage  of  free 
hvdrochloric  acid  may  exceed  0.25.  The  patients  complain  prin- 
cipally of  a  disagreeable  sense  of  pressure  and  of  burning  in  the 
epigastrium.  The  condition  at  times  accompanies  a  number  of 
diseases  of  the  stomach,  as,  for  instance,  round  ulcer  of  the  stom- 
ach ;  and  it  occurs  also  as  an  independent  neurosis,  particularly  in 
neurasthenics.  In  the  latter  event  efforts  should  be  directed  to 
the  relief  of  the  primary  disorder.  In  addition,  systematic  irri- 
gation of  the  stomach  Avith  Carlsbad  salt  (1  teaspoonful  dissolved 
in  1  quart  of  tepid  water)  should  be  practised,  and  a  generous 
animal  diet,  including  but  little  amylacea,  be  permitted,  as  the 
digestion  of  starch  is  particularly  interfered  with  by  the  excess 
of  free  hydrochloric  acid. 

ANACHLORHYDRIA  AND  HYPOCHLORHYDRIA. 

Anachlorhydria  and  hypochlorhydria  are  known  also  as  an- 
acidity  and  hypacidity  or  subacidity,  and  are  characterized  by 
either  total  absence  of  free  hydrochloric  acid  from  the  gastric 
contents  or  its  presence  in  amounts  below  0.15  per  cent.  The 
total  acidity  may  be  below  30.  These  conditions  occur  in  con- 
junction with  certain  diseases  of  the  stomach  (acute  and  chronic 
gastric  catarrh,  gastric  carcinoma,  amyloid  degeneration  of  the 
gastric  mucous  membrane,  excessive  cicatrix-formation),  but  they 
may  occur  also  as  independent  neuroses  of  the  stomach.  I  have 
observed  them   with  particular  frequency  in  association  with  a 


GASTRIC  NEUROSES  241 

wandering  right  kidney  and  gastroptosis.     They  are  encountered 
also,  as  a  rule,  in  the  presence  of  fever  and  of  anemic  states. 

The  treatment  consists  in  the  administration  of  dilute  hydro- 
chloric acid  (10  drops  in  a  wine-glassful  of  tepid  water  half  an 
hour  after  meals),  and  in  the  correction  of  the  primary  disorder. 

HYPERSECRETION  OF  THE  GASTRIC  JUICE   (GASTROSUCCORRHEA). 

Hypersecretion  of  the  gastric  juice,  also  known  as  gastro- 
succorrhea,  is  characterized  by  the  presence  in  the  stomach,  even 
in  the  morning  before  food  is  taken,  of  as  much  as  several  hun- 
dred cubic  centimeters  of  fluid,  which,  from  the  amount  of  free- 
hydrochloric  acid  that  it  contains,  and  its  ability  to  digest  albumin, 
is  without  doubt  gastric  juice.  The  disorder  may  be  associated 
with  hyperchlorhydria,  and  particularly  under  such  conditions  the 
patients  usually  complain  during  the  night  of  a  sense  of  boring 
and  of  burning  in  the  epigastrium,  and  of  increased  thirst.  The 
affection  may  be  persistent  or  occur  periodically,  so  that  a  distinc- 
tion must  be  made  between  continuous  and  paroxysmal  gastrosuccor- 
rhea.  Relief  can  be  afforded  by  systematic  irrigation  of  the  stom- 
ach with  a  lukewarm  solution  of  Carlsbad  salt  (1  teaspoonful  to 
1  quart  of  tepid  water),  and  by  the  use  of  animal  food,  particularly 
at  night.  In  addition,  the  nervousness  usually  present  will  require 
treatment. 

MIXED  NEUROSES  OF  THE  STOMACH. 

NERVOUS  DYSPEPSIA. 

Symptoms,  Diagnosis,  and  Prognosis. — Dyspepsia  sig- 
nifies primarily  only  embarrassed  gastric  digestion.  This  mani- 
fests itself,  in  cases  of  nervous  dyspepsia,  particularly  by  the 
development  of  various  discomforts  after  the  ingestion  of  food. 
A  sense  of  pressure  in  the  epigastrium,  abdominal  distention,  and 
frequent  eructation  are  complained  of  with  especial  frequency. 
In  addition  there  occur  general  nervous  disturbances,  particularly 
a  sense  of  pressure  in  the  head,  mental  confusion,  vertigo,  tinnitus 
aurium,  a  sense  of  fear,  palpitation  of  the  heart,  redness  of  the 
skin,  sweating,  and  the  like.  Examination  of  the  functional 
activity  of  the  stomach  frequently  discloses  the  existence  of  ana- 
chlorhydria  or  hypochlorhydria  and  diminution  in  the  motor 
activity  of  the  stomach,  while,  on  the  other  hand,  all  signs  indica- 
tive of  anatomic  alteration  in  the  stomach  are  wanting.  The 
patients  are  generally  conspicuous  on  account  of  their  pallid 
appearance,  and  frequently  also  by  reason  of  their  emaciation. 
In  addition,  they  usually  exhibit  evidences  of  neurasthenia  or 
hysteria.  The  disorder  is  troublesome  and  obstinate,  but  the 
prognosis  is  good,  as  it  is  scarcely  capable  of  causing  death. 

j^tiology. — Nervous  dyspepsia  is  a  common  result  of  neuras- 

16 


242  DIGESTIVE  ORGANS 

thenia,  hysteria,  and  hypocliondriasis.  As  modern  methods  of 
living  are  highly  conducive  to  the  development  of  neurasthenia, 
it  should  not  occasion  surprise  that  nervous  dyspepsia  is  a  common 
disease  <»f  the  stomach. 

Treatment. — Nervous  dyspepsia  will  be  most  successfully 
treated  if  attention  is  directed  primarily  toward  the  general  ner- 
vous condition.  In  addition,  a  nutritious  but  easily  digestible  diet 
should  be  prescribed.  It  is  noteworthy  that  the  patients,  as  a  rule, 
l)ear  badly  courses  of  treatment  at  the  springs,  such  as  are  fre- 
quently directed  by  physicians  who  have  attributed  the  symptoms 
of  nervous  dyspepsia  to  anatomic  alterations  in  the  stomach. 

Under  the  name  of  periodic  vomiting  v.  Leyden  has  described  attacks 
of  vomiting,  associated  with  gastralgia,  occurring  in  anemic  and  nervous 
individuals.  Rossbach  has  designated  as  gristroxyims  attacks  of  excessive 
secretion  of  hydrochloric  and  lactic  acids  in  the  stomach,  giving  rise  to 
vomiting,  headache,  and  vertigo.  Xervous  individuals  and  heavy  smokers 
especially  are  attacked.  The  condition  can  be  relieved  by  irrigation  of  the 
stomach.  The  attacks  not  rarely  can  be  controlled  by  the  ingestion  of  hot 
water. 


V.    DISEASES   OF  THE   INTESTINES. 


ACUTE  INTESTINAL  CATARRH. 

Ktiology. — Like  acute  gastric  catarrh,  acute  intestinal  catarrh 
also  develops  most  commonly  as  a  result  of  dietetic  errors,  and  fre- 
quentlv  both  disorders  exist  together.  Explanation  is  scarcely 
required  for  the  fact  that  if  the  contents  of  the  stomach  are 
abnormally  irritating  the  intestines  also  will  be  involved  in  the 
morbid  process  as  soon  as  it  has  taken  up  the  irritating  gastric 
contents.  The  nature  of  the  dietetic  error  may  be  most  varied. 
Excess  in  food  and  drink  may  readily  become  injurious  from  the 
occurrence  of  fermentation  in  the  ingested  matters  in  the  digestive 
tract,  with  irritation  of  the  mucous  membrane.  Acute  intestinal 
catarrh  develops  still  more  readily  after  the  ingestion  of  decomposed 
food  and  drink,  as,  for  instance,  after  the  eating  of  unripe  fruit  or 
vegetables,  fermented  drinks,  putrid  water,  etc.  In  this  category 
belongs  also  the  acute  intestinal  catarrh  of  children,  which  occurs 
with  especial  frequency  in  the  hot  months  of  summer,  and  is  de- 
pendent upon  fermentation  of  the  milk  ingested.  Also,  the  inges- 
tion of  food  that  is  too  hot  or  too  cold,  or  is  insufficiently  masticated, 
or  is  indige.stible,  is  capable  of  inducing  acute  intestinal  catarrh. 
Some  persons  exhibit  an  idiosyncrasy  to  certain  kinds  of  food,  as, 
for  instance,  cucuralu-rs,  prunes ;  that  is,  they  develop  symptoms 
of  acute  intestinal  catarrh  regularly  after  the  ingestion  of  certain 
articles  of  food,  even  when  these  are  taken  in  the  smallest  amounts. 


ACUTE  INTESTINAL   CATARRH  243 

Aeute  intestinal  catarrh  of  toxic  origin  develops  after  the  swal- 
lowing of  certain  irritant  poisons  (acids,  alkalies,  arsenic,  mercuric 
chloric!),  but  this  is  not  a  common  mode  of  origin.  Acute  intes- 
tinal catarrh  may  be  caused  also  by  excessive  use  of  purgatives. 
There  is  no  doubt  that  refrigeratory  {rheumatic)  intestinal  catarrh 
resulting  from  exposure  to  cold  occurs.  Thus,  a  cold  bath  when 
the  bodv  is  in  a  state  of  perspiration  may  give  rise  to  acute 
intestinal  catarrh  ;  sleeping  upon  damp  ground  has  also  at  times 
been  found  to  be  a  cause.  I  have  in  several  instances  observed 
acute  intestinal  catarrh  to  occur  after  the  application  of  an  ice-bag 
to  the  abdomen,  so  that  it  became 'necessary  to  withhold  the  appli- 
cation. Scarcely  anything  is  known  definitely  with  regard  to  trau- 
matic intestinal  catarrh  in  so  far  as  external  injuries  are  concerned. 
On  the  other  hand,  acute  intestinal  catarrh  may  result  from  inter- 
nal injuries,  as,  for  instance,  in  connection  Avith  constipation,  in 
C(msequence  of  the  irritation  due  to  hardened  scybalous  masses, 
after  the  swallowing  of  bones  or  fruit-stones,  and  from  the  presence 
of  biliary  calculi  in  the  bowel.  Possibly  some  cases  of  acute 
intestinal  catarrh  associated  with  the  presence  of  worms  in  the 
intestine  should  be  included  in  this  category.  Epidemic  acute 
intestinal  catarrh  occurs  at  times  in  the  hot  months  of  summer  or 
atitumn  as  an  independent  disorder.  It  may  be  so  severe  as  to 
suggest  the  clinical  picture  of  Asiatic  cholera,  and  it  has  then  been 
designated  also  cholera  nostras  s.  europaea.  Secondary  acute  intes- 
tinal catarrh  may  either  arise  by  extension  from  adjacent  disease 
(peritonitis)  or  accompany  other  intestinal  or  constitutional  disease 
(typhoid  fever,  dysentery,  cholera,  carcinoma  of  the  intestine,  in- 
vagination of  the  intestine,  febrile  infectious  diseases,  etc.).  Acute 
intestinal  catarrh  occurs  at  all  periods  of  life.  It  attains  a  wide 
distribution  in  infancy  on  account  of  the  readiness  with  which  milk 
undergoes  fermentation,  and  annually  many  thousands  of  children 
die  from  acute  gastro-enteritis — cholera  infantum. 

Anatomic  Alterations. — An  inflamed  intestinal  mucous 
memljrane,  like  other  inflamed  mucous  membranes,  exhibits  red- 
ness, swelling,  and  increased  secretion.  The  redness,  which  results 
from  distention  of  the  vessels  of  the  mucous  membrane  with 
blood,  is  usually  most  pronounced  upon  the  summit  of  the  villi 
and  the  prominences  of  the  folds.  Here  and  there,  probably, 
some  blood-vessels  have  ruptured  and  small  hemorrhages  have 
taken  place.  The  swelling  of  the  mucous  membrane  is  appreciable 
in  the  increased  thickness  of  the  tissues  and  excessive  infiltration 
with  blood-plasma.  The  lymph-follicles  are  involved  in  the  swell- 
ing with  especial  regularity.  They  are  increased  in  size,  and  are 
usually  surrounded  by  a  zone  of  hyperemic  vessels.  At  first  the 
swelling  of  the  lymph-follicles  depends  only  upon  serous  infiltra- 
tion. They  therefore  resemble  watery  vesicles,  and  on  puncture 
they  give  exit  to  a  drop  of  clear  fluid,  while  they  collapse  at  the 


244  DIGESTIVE  ORGANS 

same  time.  Later,  on  the  other  hand,  inflammatory  hyperplasia 
of  lymph-cells  takes  place  in  them,  and  they  then  acquire  an 
opaque  appearance  and  no  longer  collapse  when  punctured.  The 
increased  secretion  of  the  mucous  membrane  is  manifested  by  the 
accumulation  upon  the  surface  of  the  membrane  of  vitreous  mucus, 
or  mucus  presenting  a  greenish-gray  mottling  in  consequence  of 
admixture  with  exfoliated  epithelial  cells  or  with  pus.  If  the 
iuHammation  of  the  mucous  membrane  be  intense,  it  will  extend 
to  the  serosa,  which  then  appears  markedly  hy])eremic  and  of  a 
rose  tint.  The  contents  of  the  intestine  are  usually  thin  and  fluid. 
Not  rarely  they  consist  of  a  flocculent  admixture  of  exfoliated  epi- 
thelial cells  from  the  intestinal  mucous  membrane.  If  the  intestinal 
evacuations  have  been  numerous  and  copious,  the  contents  of  the 
bowel  may  be  gray  and  deficient  in  bile.  In  connection  with 
severe  intestinal  catarrh  the  mesenteric  lymphatic  glands  may  also 
be  involved  and  present  swelling  and  redness.  Acute  intestinal 
catarrh  may  involve  the  entire  bowel  or  only  certain  sections;  and 
in  the  latter  event,  in  accordance  with  the  seat  of  the  disease,  a 
distinction  has  been  made  between  acute  duodenitis,  jejunitis, 
ileitis,  typhlitis  (catarrh  of  the  cecum),  appendicitis  (catarrh  of  the 
vermiform  appendix),  colitis,  and  proctitis  (catarrh  of  the  rectum). 
Ileocolitis  is  most  commonly  encountered.  It  is  worthy  of  note 
that  not  rarely  the  most  intense  manifestations  during  life  are 
attended  with  only  slight  alterations  in  the  intestinal  mucous 
membrane,  obviously  because  a  portion  of  the  anatomic  changes 
has  disappeared  in  the  cadaver. 

Among  the  comjjlications  of  acute  intestinal  catarrh  superficial  loss  of 
tissue,  erosions  of  the  bowel.,  more  profound  ulceration  of  the  mucous  membrane, 
and  destruction  of  the  bjmph-foUicles  of  the  intestine  may  be  mentioned. 

Symptoms  and  Diagnosis. — The  symptoms  of  acute  intes- 
tinal (iatarrh  vary  in  accordance  with  the  extent  of  the  disease 
and  with  the  portion  of  the  bowel  involved.  If  the  large  intestine 
is  the  seat  of  the  disease,  diarrhea  occurs,  in  consequence  of  the 
increased  peristaltic  activity  ;  the  contents  of  the  bowel  are  so 
rapidly  sent  through  the  large  intestine  that  sufficient  time  is  not 
allowed  for  inspissation  to  take  place.  Catarrhal  conditions  con- 
fined to  the  small  intestine,  on  the  other  hand,  are  unattended 
with  diarrhea,  for  the  fecal  matter  acquires  its  usual  consistency 
in  the  uninjured  large  intestine. 

In  the  most  common  variety  of  acute  intestinal  catarrh — Uco- 
colitis — there  occur,  at  first,  in  many  cases  rumbling  and  noises  in 
the  abdomen — borborygmi — which  result  from  unusually  active  and 
vigorous  intestinal  movement  and  the  associated  rapid  propulsion 
of  the  intestinal  contents.  In  consequence  of  decomposition  of 
the  intestinal  contents  there  is  active  development  of  gas  in  the 
bowel,  and  the  abdomen  becomes  distended — intestinal  meteorism 
or  tympanites.     The  gas  seeks  a  means  of  exit  downward,  and  fre- 


ACUTE  INTESTINAL  CATARRH  245 

quently  flatus  occurs,  and  this  is  often  attended  with  an  offensive, 
ahiiost  fetid  odor.  Often  there  is  frequent  desire  for  stool,  and  the 
stools  themselves  are  thin,  not  rarely  like  water.  The  dejections 
are  frequently  marked  by  a  decomposing  or  putrid  odor,  and  they 
vary  between  brown,  yellow,  green,  and  gray  in  color.  At  times 
the  stools  contain  unusually  large  amounts  of  undigested  food 
(meat-fibers,  tendon,  portions  of  vegetables) — so-called  lientery. 
Of  especial  significance  in  diagnosis  is  the  presence  of  mucus  in 
the  stools.  The  appearance  of  blood  is  one  of  the  less  common 
phenomena.  The  reaction  of  the  stools  is  usually  acid.  Fre- 
quently the  evacuated  matters  are  abundantly  admixed  with  gas, 
and  are  frothy.  Microscopic  examination  of  the  feces  discloses, 
in  addition  to  numerous  remains  of  food,  desquamated  epithelial 
cells,  round  cells,  and  crystals  of  cholesterin,  fat  at  times,  also 
Charcot-Neumann  crystals  (pointed  double  pyramids),  and,  besides, 
numerous  bacteria,  although  it  has  not  yet  been  possible  to  isolate 
specific  bacteria.  Yeast-cells  also  are  frequently  found  in  the 
stools.  The  number  of  bowel-movements  is  subject  to  great 
variation  (from  two  to  twenty  in  twenty-four  hours).  At  times 
the  patients  are  scarcely  able  to  leave  the  commode,  from  a  fear 
that  they  will  at  once  again  be  compelled  to  resort  to  it,  and  that 
they  may  fail  to  reach  it  in  time.  The  desire  for  stool  appears 
with  especial  frequency  after  the  ingestion  of  food.  It  is  fre- 
quently preceded  by  abdominal  pain — tormina ;  or  there  is  escape 
of  gas  after  pain  has  first  appeared  in  the  abdomen,  and  this  like- 
wise changes  its  position  with  the  onward  movement  of  the  gas. 
If  gastric  catarrh  exist  in  addition  to  intestinal  catarrh,  there  will 
be  present  nausea,  vomiting,  loss  of  appetite,  and  coated  tongue. 
Often  there  is  labial  herpes. 

Acute  intestinal  catarrh  may  be  unattended  with  alteration  in 
the  bodily  temperature,  while  in  other  instances,  on  the  contrary, 
febrile  movement  is  observed.  Many  patients  complain  of  gen- 
eral languor  and  malaise,  and  of  drawing  pains  in  the  muscles 
and  joints.  Thirst  is  usually  increased  under  all  conditions,  in 
consequence  of  the  loss  of  fluid  with  the  loose  bowel-movements. 
The  abdomen  is  frequently  distended  and  tender  to  touch.  The 
urine  is  usually  voided  in  diminished  amount.  It  is  concentrated, 
and  often  deposits  a  sediment  of  urates.  The  amount  of  indican 
is  frequently  increased.  Not  rarely  there  is  slight  albuminuria, 
with  cylindruria.  Severe  diarrhea  causes  a  sense  of  weakness,  and 
may  even  give  rise  to  manifestations  of  collapse.  As  in  Asiatic 
cholera,  there  may  also  be  pains  in  the  muscles,  especially  in 
those  of  the  calves,  and  the  voice  may  be  high  and  hoarse. 

The  duration  of  acute  ileocolitis  varies  from  a  few  days  to 
between  two  and  four  weeks.     In  adults  recovery  is  the  rule. 

Acute  catarrhal  duodenitis  can  be  recognized  only  when  the 
choledoch  duct  also  is  involved  in  the  morbid  process.     This  may 


246  DIGESTIVE  ORG  Ays 

result  from  obstruction  at  the  orifice  of  this  duct  in  consequence 
of  tiie  swelling  of  the  duodenal  mucous  membrane  ;  or  from  the 
entrance  of  a  plug  of  mucus  from  the  intestinal  mucous  membrane 
into  the  duct  and  causing  its  occlusion  ;  or,  finally,  from  thicken- 
ing of  the  mucous  membrane  of  the  duct  in  consequence  of  partici- 
pation in  the  inflammatory  process.  Under  all  of  these  condi- 
tions biliary  stasis  and  icterus  develop,  and  the  condition  has  then 
been  designated  gastroduodenal  icterus,  or  catarrhal  jaundice. 

JeJiDiitis  and  ileitis  cannot  be  diagnosed  with  certainty. 

Typhlitis  and  appendicitis  will  be  considered  in  a  special  section. 

Proctitis  is  characterized  by  persistent  desire  for  stool  and  pain 
when  the  bowels  are  moved — anal  tenesmus.  The  anal  sphincter 
is  usually  contracted  spasmodically.  Digital  examination  of  the 
rectum  causes  severe  pain.  The  mucous  membrane  of  the  rectum 
seems  hot  and  unusually  relaxed.  Considerable  mucus  remains 
adherent  to  the  finger,  which  at  times  is  streaked  and  dotted  with 
blood.  After  the  condition  has  existed  for  some  time  paralysis 
of  the  anal  sphincter  sometimes  develops,  so  that  thin  fecal  matter 
escapes  continuously  from  the  rectum,  moistens  and  irritates  the 
skin  in  the  anal  region,  and  excites  inflammatory  reaction.  There 
may  also  be  prolapse  of  the  bowel. 

Prognosis. — The  prognosis  of  acute  intestinal  catarrh  is 
favorable  if  the  disease  occurs  in  adults,  and  no  serious  primary 
disorder  is  present.  In  infants  acute  intestinal  catarrh  is  quite  a 
serious  disease,  and  in  the  aged  also  there  is  danger  that  death 
may  result  from  asthenia. 

Treatment. — Prophylactic  measures  may  be  extremely  use- 
ful. Care  in  diet  particularly  should  be  observed.  The  treatment 
of  acute  intestinal  catarrh  depends  upon  the  causative  factors — 
causal  therapy — and  in  part  also  upon  the  seat  of  the  disease.  In  all 
varieties  of  the  disease  a  febrile  patient  with  frequent  bowel-move- 
ments should  remain  in  bed,  keep  a  hot  poultice  applied  constantly 
to  the  abdomen,  and  avoid  solid  food  for  several  days.  AVeak  tea, 
coffee,  Avater  Mith  red  wine,  mucilaginous  soups,  and  almond- 
milk  may  be  permitted.  Should  intestinal  catarrh  be  dependent 
upon  dietetic  errors,  it  is  often  most  advantageous  to  prescribe  a 
purgative  (castor-oil,  25  c.c. — 6  teaspoonfuls — in  a  cuj)  of  coffee  ; 
or  calomel,  0.5 — 7^  grains),  in  order  to  expel  speedily  tiie  ferment- 
ing and  irritating  intestinal  contents.  OfttMi  the  symptoms  disap- 
pear as  soon  as  the  bowels  are  emptied.  Sliould  the  diarrhea  per- 
sist, and  frequent  rumbling  indicate  abnormal  increase  in  intestinal 
peristalsis,  preparations  of  opium  should  be  prescribed  in  order  to 
keep  the  bowels  quiet. 

R   Powdered  opium,  0.03  (  I  grain  )  ; 

Sugar,  0.5     (7^  grains). — M. 
Make  10  such  powders. 
Dose  :  1  powder  every  three  hours. 


ACUTE  GASTRO-INTESTINAL   CATARRH  IN  INFANTS    247 

R   Powder  of  ipecacuanha  and  opium,  0.3  (4^  grains) ; 

Sugar,  0.5  (7^      "     ).— M. 

Make  10  such  powders. 
Dose  :  1  powder  every  three  hours. 

R  Tincture  of  opium, 

Ethereal  tincture  of  valerian,         each,  10.0  (2^  fluidrams). — M. 
Dose :  20  drops  thrice  daily  upon  sugar. 

R   Morphin  hydrochlorate,  0.3  (4^  grains) ; 

Glycerin, 

Distilled  water,  each,  6.0  (75  minims). — M. 

Dose :  From  0.25  to  0.5  (4  to  8  minims)  subcutaneously. 

It  is  often  useful  to  combine  preparations  of  opium  with  astrin- 
gents (styptics) ;  a  combination  of  bismuth  salicylate  with  opium 
is  particularly  reliable : 

R   Bismuth  salicylate,  0.5  (72  grains)  ; 

Powdered  opium,  0.03  (J  grain) ; 

Bugar,  0.3  (4^  grains).— M. 

Make  10  such  powders. 
Dose :  1  powder  every  three  hours. 

Duodenitis  and  gastroduodenal  catari'li  should  be  treated  accord- 
ing to  the  rules  that  have  been  laid  down  for  the  treatment  of 
acute  gastric  catarrh.  If  jaundice  be  present,  special  care  should 
be  taken  that  all  fatty  substances  are  excluded  from  the  diet. 
Acute  injiammation  of  the  rectum  is  readily  accessible  to  local  treat- 
ment, particularly  with  irrigation  of  the  bowel  (infusion)  and 
suppositories.  The  latter,  containing  narcotics,  may  be  employed 
especially  when  tenesmus  is  severe  ;  for  instance  : 

R    Morphin  hydrochlorate,  0.03  (J  grain) ; 

Cocoa-butter,  sufficient  to  make  3  suppositories. 

Dose :  1  suppository  twice  or  thrice  daily. 

ACUTE  GASTRO-INTESTINAL  CATARRH  IN 

INFANTS. 

i^tiology. — Infants  are  in  high  degree  predisposed  to  acute 
gastro-intestinal  catarrh,  and  a  large  number  of  children  succumb 
annually  to  this  disease.  In  the  first  place,  milk  is  a  readily  decom- 
posed article  of  food,  and,  besides,  the  gastro-intestinal  mucous  mem- 
brane of  infants  appears  particularly  sensitive.  Experience  has 
shown  that  infants  ffiven  mother's  or  wet-nurse's  milk  suffer  much 
less  commonly  than  those  nourished  with  cow's  milk  or  substitutes 
for  milk.  Milk  undergoes  decomposition  the  more  readily  the  higher 
the  external  temperature,  and  in  accordance  with  this  fact  acute 
gastro-intestinal  catarrh  occurs  with  especial  frequency  in  the  hot 
months  of  summer  and  autumn  (from  July  to  September).  The  con- 
dition has,  therefore,  also  been  designated  summer  diarrhea  of  infants. 
The  greater  the  want  of  cleanliness  in  the  dairies  from  which  the 
milk  is  obtained,  the  greater  is  the  danger  of  fermentative  bac- 


248  DIGESTIVE  ORGANS 

teria  gaining  entrance  into  the  milk,  especially  with  small  particles 
of  excrement  from  the  cow,  so  that  the  milk  is  contaminated  from 
the  ontset.  It  is  important  that  the  milk  be  thoroughly  boiled, 
in  order,  so  far  as  possible,  to  destroy  fermentative  bacteria ;  that 
the  receptacles  for  the  milk  be  kept  cold  and  covered  ;  that  rem- 
nants of  milk  not  drunk  by  the  infant  be  thrown  away  or  be  used 
for  other  purposes ;  and  that  the  bottles  and  the  nipples  be  kept 
scrupulously  clean.  Failure  to  observe  these  precautions  may 
expose  the  infant  to  grave  danger.  At  times  error  is  committed 
in  giving  the  infant  milk  in  too  large  quantities  or  at  irregular 
intervals.  Experience  has  shown  that  infants  bear  poorly  the  milk 
of  cows  supplied  with  green  fodder.  Dentition  undoulitedly  pre- 
disposes to  gastro-intestinal  catarrh.  It  is  not  rarely  observed 
that  a  perfectly  healthy  child  is  attacked  by  diarrhea,  and  in 
spite  of  the  greatest  care  in  feeding,  only  when  a  new  tooth  is  in 
process  of  irruption — so-called  dentition-diarrhea.  The  circum- 
stance that  the  connection  between  the  two  conditions  is  not  recog- 
nized cannot  justify  doubt  of  the  fact  itself.  Some  infants  are 
attacked  by  severe  acute  gastro-intestinal  catarrh  when  the  attempt 
is  made  to  wean  them  from  an  exclusive  milk-diet — diarrhoea 
ablactatorum  ;  and  at  times  the  disease  cannot  be  controlled  until 
the  exclusive  milk-diet  is  resumed.  The  sensitiveness  of  the 
infant's  stomach  and  intestines  with  regard  to  a  milk-diet  may 
be  recognized  from  the  fact  that  some  breast-fed  infants  are 
attacked  by  diarrhea  when  the  mother  or  the  nurse  becomes  angry, 
or  suffers  other  psychic  disturbance,  or  with  the  occurrence  of 
menstruation.  At  times  also  a  sort  of  idiosyncrasy  is  observed — 
one  child  not  tolerating  the  milk  of  a  given  nurse,  while  another 
child  may  tlirive  upon  it.  Children  of  the  lower  classes  suffer  most 
commonly  from  acute  gastro-intestinal  catarrh,  because  less  atten- 
tion is  devoted  to  their  care.  The  poor  also  cannot  always  pro- 
vide proper  milk  on  account  of  the  expense.  It  is,  therefore,  not 
remarkable  that  the  disease  is  particularly  prevalent  in  large  cities, 
niegitimate  children  perish  in  large  number,  because  they  are 
placed  at  board  at  the  smallest  possible  cost,  and  in  consequence 
are  poorly  nourished  and  cared  for.  Such  foster-mothers  are 
appropriately  designated  "  angel-makers." 

Symptoms  and  Diagnosis. — The  earliest  symptoms  of 
acute  gastro-intestinal  catarrh  in  infants  often  consist  in  frequent 
eructation  and  vomiting.  The  vomited  matter  at  first  contains 
lumps  of  casein  ;  but  if  the  vomiting  has  persisted  for  some  time 
the  milk  is  returned  uncoagulated,  obviously  because  the  gastric 
juice  has  become  too  deficient  in  acid  to  effect  coagulation  of  the 
milk.  Soon  diarrhea  sets  in,  and  in  some  cases  it  may  be  the 
earliest  symptom  ;  or,  if  the  bowel  principally  be  involved,  it  may 
be  unattended  with  vomiting.  The  stools  become  thin,  exhale  a 
fetid  and  acid  odor,  and  are  either  greenish  in  color  or  yellowish 


ACUTE  G ASTRO-INTESTINAL   CATARRH  IN  INFANTS    249 

when  evacuated,  but  when  exposed  to  the  air  soon  acquiring  a 
greenish  hue.  If  the  bowels  move  with  great  frequency,  the  stools 
present  a  grayish  color,  and  the  condition  is  then  designated 
cholera  infantum.  The  abdomen  frequently  is  greatly  distended  in 
consequence  of  excessive  development  of  gas  in  the  intestine. 
From  time  to  time  rumbling  and  gurgling  sounds — borborygmi — are 
audible,  indicating  increased  intestinal  peristalsis  and  rapid  pro- 
pulsion of  the  fluid  intestinal  contents.  From  time  to  time  the 
little  patient  cries  aloud,  distorts  the  face  in  pain,  and  draws  the 
legs  upon  the  abdomen,  in  consequence  of  paroxysmal  abdominal 
pain — tormina.  Frequently  escape  of  fetid  gas  follows,  not  rarely 
associated  with  fluid  intestinal  contents.  When  the  diarrhea  has 
existed  for  some  time  inflammatory  redness  of  the  skin  about  the 
anus  and  the  buttocks  develops,  because  soiling  and  irritation  of 
the  parts  by  fecal  matter  are  unavoidable.  The  secretion  of  urine 
almost  ceases  entirely.  The  urine  frequently  contains  albumin 
and  tube-casts  and  considerable  indican.  In  consequence  of  the 
copious  loss  of  water  in  the  stools  thirst  is  greatly  increased, 
and  the  mouth  feels  sticky  and  dry.  The  peripheral  portions  of 
the  body  are  usually  cool,  while  the  covered  portions  of  the  trunk 
are  unusually  hot,  in  consequence  of  febrile  elevation  of  the  in- 
ternal temperature.  Unfortunately,  rapid  and  dangerous  collapse 
often  occurs  in  the  course  of  the  disease.  The  face  becomes 
shrunken  and  presents  a  tired  and  aged  appearance.  The  fon- 
tanels also  become  depressed,  and  the  margins  of  the  cranial  bones 
can  be  slightly  moved  upon  one  another,  the  voice  becomes  faint 
and  feeble,  movement  is  painful  and  difficult,  and  the  action  of 
the  heart  is  greatly  accelerated.  In  consequence  of  progressive 
anemia  of  the  brain  cerebral  manifestations  appear  that  have  been 
designated  hydrocephaloid.  At  the  same  time  the  little  patient 
becomes  more  and  more  apathetic,  lying  with  its  eyes  half  closed, 
and  presenting  tonic  twitchings  of  the  face  or  in  the  extremities ; 
finally,  general  clonic  spasms  may  occur  and  death  result. 

In  rare  instances  the  exposed  cornea  becomes  desiccated  and  it  may 
undergo  rupture. 

Anatomic  Alterations. — In  the  acute  gastro-intestinal 
catarrh  of  infants  the  statement  already  emphasized  in  connec- 
tion with  acute  intestinal  catarrh,  that  the  most  intense  symptoms 
during  life  are  often  associated  with  only  slight  alterations  in  the 
intestinal  mucous  membrane,  is  frequently  confirmed.  In  addi- 
tion to  fluid  intestinal  contents,  not  rarely  only  slight  swelling  of 
the  lymphatic  follicles  is  found  besides,  and  these  are  surrounded 
by  a  garland  of  dilated  blood-vessels.  In  other  instances  the 
lesions  of  acute  gastro-intestinal  catarrh  already  described  are 
found. 

Prognosis. — Acute  gastro-intestinal  catarrh  in  infants  is  a 


250  DIGESTIVE  ORGANS 

most  serious  disease,  and  the  prognosis  is  grave.  This  depends 
especially  upon  the  cooperation,  the  intelligence,  and  the  care,  in 
part  upon  the  means,  of  those  upon  whom  the  nursing  of  the  sick 
child  devolves. 

Treatment. — Prophylactic  measures  first  of  all  require  thor- 
ough discussion  and  consideration.  These  apply  to  the  nourish- 
ment of  the  infant.  The  most  natural  and  the  best  food  for  an 
infant  is  the  breast-milk  of  its  mother  or  of  a,  wet-nurse.  Unfortu- 
nately, however,  it  is  a  growing  custom  that  mothers,  from  motives 
of  convenience  or  from  the  unfounded  fear  that  their  beauty  will 
suffer  in  consequence  of  nursing,  do  not  nurse  their  children  ; 
apart  from  those  instances  in  which  mothers  are  forljidden  by 
physicians  to  nurse  their  children ;  for  instance,  at  an  age  below 
eighteen  years,  in  the  presence  of  profound  anemia,  pulmonary 
tuberculosis,  inherited  nervous  disease  (epilepsy,  neurasthenia, 
psychopathy),  and  the  like.  The  employment  of  a  wet-nurse  is 
expensive,  and  therefore  accessible  only  to  families  of  means. 
Further,  certain  precautions  should  be  observed  in  nourishing 
infants  with  the  breast-milk  of  the  mother  or  of  a  wet-nurse. 
Infants  readily  develop  gastro-intestinal  catarrh  when  nursing 
women  indulge  in  acid  food,  or  become  greatly  excited,  or  permit 
coitus,  or  menstruate.  It  also  happens  occasionally  that,  from 
causes  that  elude  scrutiny,  the  infant  fails  to  thrive,  although  the 
nurse  is  apparently  faultless,  "while  it  bears  admirably  the  milk 
of  another  nurse  possibly  not  presenting  so  good  an  appearance. 
Under  such  circumstances  a  change  should  be  made  in  good  time. 
Should  acute  gastro-intestinal  catarrh  develop  on  weaning  the 
infant,  there  is  no  other  remedy  but  to  restore  the  child  to  the 
breast  and  to  repeat  tlie  attempt  at  weaning  at  a  later  period. 

In  cases  in  which  nourishment  at  the  breast  of  the  mother  or  of  a 
wet-nurse  is  not  practicable, /e^f/Z/ii^  icith  animal  milk  is  the  next  best 
method,  and,  as  a  rule,  cow's  milk  is  then  employed.  Goat's  milk 
is  less  digestible  on  account  of  the  greater  amount  of  fat  and  albu- 
min that  it  contains,  and  mare's  and  ass's  milk,  which  more  closely 
resemble  human  milk  in  chemic  constitution  than  does  cow's  milk, 
are  not  generally  available.  The  use  of  cow's  milk  is  attended 
with  two  dangers — namely,  infection  with  tuberculosis  and  undue 
readiness  of  decomposition.  Tuberculosis  is  common  in  cows,  and 
it  may  readily  happen  that  tubercle-bacilli  gain  entrance  into  the 
milk,  especially  when  tuberculous  nodules  have  developed  in  the 
udder,  and  the  milk  is  thus  infective.  This  danger  cannot  be 
averted  with  certainty,  although  it  can  be  diminished  if  the  cow 
whose  milk  is  to  be  used  is  most  carefully  examined  for  the  pres- 
ence of  tuberculosis,  and  is  no  longer  employed  if  even  suspicious 
signs  are  present,  and,  besides,  if  the  milk  is  always  thoroughly 
boiled  for  a  considerable  length  of  time  liefore  it  is  used,  in  order 
to  effect  destruction  of  any  tubercle-bacilli  or  their  spores.     The 


ACUTE  GASTRO-INTESTINAL  CATARRH  IN  INFANTS    251 

suggestion  appears  worthy  of  consideration,  to  use  the  milk  of 
several  cows,  in  order  to  attenuate  such  tuberculous  virus  as  may 
be  present. 

In  order  to  prevent,  so  far  as  possible,  the  decomposition  of 
milk,  cleanliness  of  the  dairy  and  of  the  dairy-utensils  should 
be  observed,  and  cleansing  the  udder  of  adherent  contamina- 
tions before  milking,  and  of  the  fingers  and  the  hands  of  the 
milker,  practised.  The  milk  should  at  once  be  covered  and  kept 
in  a  cool  place.  The  cows  should  be  supplied  with  dry  fodder.  In 
large  cities  establishments  for  the  supply  of  infants'  milk  exist,  which 
engage  in  the  preparation  of  milk  for  infants  in  accordance  with 
the  principles  outlined.  Milk  is  also  sterilized  by  many  establisli- 
ments,  and  is  sold  in  this  condition.  As  may  be  understood,  the 
greater  labor  expended  in  obtaining  such  milk  entails  a  higher 
price  for  the  product,  and  therefore  the  poor  are  scarcely  able  to 
purchase  this  specially  prepared  article.  In  this  connection  private 
philanthropy  may  render  a  great  service  by  disj^ensing  such  milk 
under  proper  conditions.  To  sterilize  milk  in  private  dwellings, 
the  use  of  the  apparatus  of  Soxhlet  may  be  especially  recom- 
mended. Under  all  conditions  milk  for  children  should  be  thor- 
oughly boiled  for  a  considerable  length  of  time  after  its  reception, 
and  be  introduced  into  a  clean  vessel,  which  is  covered  with  a  glass 
plate  and  is  placed  in  a  cool  spot,  and  if  possible  preserved  upon 
ice.  The  addition  of  a  tal)lespoonful  of  lime-water  to  every  quart 
of  milk  may  also  be  advised  in  order  to  prevent  fermentation. 

It  should  be  borne  in  mind  that  cow's  milk  differs  from  mother's 
milk  in  containing  a  larger  amount  of  solids,  particularly  casein ; 
W'hile,  on  the  other  hand,  it  contains  less  sugar.  In  order  to  make 
the  former  more  closely  resemi)le  the  latter  it  is  necessary  to  add 
water  and  sugar  to  cow's  milk.  Even  then  the  resemblance 
between  the  two  is  not  complete,  the  casein  of  cow's  milk  coagu- 
lating in  large  masses,  while  that  of  mother's  milk  coagulates  in 
fine  flakes.  In  consequence,  mother's  milk  is  more  readily  acces- 
sible to  the  action  of  the  gastric  juice  and  is  more  digestible  than 
cow's  milk.  By  the  addition  of  lime-water  to  cow's  milk  its  casein 
will  be  precipitated  in  small  flakes. 

Children  in  the  first  months  of  life  should  receive  cow's  milk  and  water 
in  equal  parts.  Then,  gradually,  one-tenth  less  water  is  added,  until  from 
the  fifth  month  the  child  will  receive  pure  cow's  milk.  To  each  250  c.c.  of 
milk  a  pinch  of  sugar  should  be  added.  The  use  of  sugar  of  milk  is  not 
necessary. 

For  the  preservation  of  the  health  of  the  infant  it  is  further 
important  to  regulate  the  amount  of  food  and  the  time  of  feeding. 
The  stomach  and  the  intestines  should  be  protected  from  over- 
loading, In  the  first  two  months  of  life  an  infant  should  receive 
food  every  two,  and  thereafter  every  three,  hours.  The  last  meal 
should  be  given  at  ten  o'  clock  at  night  and  the  first  at  six  in  the 


252  DIGESTIVE  ORGANS 

morning.  It  is  further  important  to  keep  the  feeding-bottles  and 
the  ni])plcs  ck-an.  The  bottle  is  thoroughly  cleansed  with  water 
and  salt  after  each  nursing,  and  is  kept  filled  with  water  until  the 
next  jueal.  Also,  the  nipples,  in  Avhich  germs  readily  lodge,  are 
thoroughly  rubbed  externally  and  internally  with  salt,  and  are  kept 
in  water.  Care  should  further  be  taken  to  have  the  mouth  of  the 
infant  cleansed  after  each  nursing  with  a  bit  of  soft,  clean  linen 
that  has  been  dipped  in  water,  as,  otherwise,  remnants  of  milk  may 
readily  undergo  fermentation  in  the  mouth,  and  if  they  be  swal- 
lowed they  may  excite  fermentative  processes  in  the  stomach.  It 
is  understood  that  the  milk  should  be  given  not  cold,  but  at  the 
temperature  of  the  body,  being  warmed  in  the  bottle  at  each 
nursing  by  being  placed  in  hot  water. 

The  feeding  of  an  hfant  icith  Hubditute.H  for  milk — as,  for  instance, 
Liebig's,  Nestle's,  Kufeke's,  Lofflund's  foods,  Biedert's  cream- 
mixture,  Gartner's  fat-milk — is  not  worthy  of  commendation, 
because  children  thus  nourished  frequently  become  rachitic  and 
also  suffer  readily  from  intestinal  catarrh.  If  acute  gastro-intes- 
tinal  catarrh  has  developed  in  an  infant,  it  is  wise  to  withhold  milk 
for  from  one  to  three  days,  and  to  replace  it  by  pure  water,  to 
which  a  little  red  wine  or  Cognac  has  been  added.  Should  the  dis- 
ease be  protracted,  Nestle's  food,  beef-tea,  or  mucilaginous  soups 
of  oatmeal-gruel,  sago,  or  arrow-root  may  be  given  instead  of  milk. 
Among  medicaments  calomel  deserves  first  place  : 

B  Mercurous  chlorid,  0.01  (  i  grain) ; 

Sugar,  0.5    {7^  grains).— M. 

Make  10  such  powders. 
Dose :  1  powder  every  two  hours. 

Among  styptics,  colombo-root  (infusion  of  colombo-root,  10.0 : 
100 — 2^  drams  :  3  fluidounces  ;  5  c.c. — 1  teaspoonful — every  two 
hours),  cascarilla-bark  (infusion  of  cascarilla-bark,  10.0  :  100 — 2^ 
drams  :  3  fluidounces  ;  5  c.c. — 1  teaspoonful — every  two  hours), 
and  silver  nitrate  (solution  of  silver  nitrate,  0.1  :  100 — 1^  grains  : 
3  fluidounces ;  5  c.c. — 1  teaspoonful — every  two  hours)  may  be 
mentioned.  Preparations  of  opium  should  not  be  prescribed, 
because  children  readily  develop  alarming  toxic  symptoms  from 
their  use.  Of  late,  disinfectants  (lactic  acid,  carbolic  acid,  benzol, 
najjhthalin,  thymol,  resorcin,  etc.)  have  been  much  used,  but  we 
fail  to  see  any  particular  advantage  in  them  over  the  remedies 
already  recommended.  If  signs  of  cerebral  anemia  appear,  strong 
Avinc  in  small  doses  should  be  administered,  and  the  head  should 
be  lowered. 

CHRONIC  INTESTINAL  CATARRH. 

^Etiology. — Chronic  intestinal  catarrh  not  rarely  develops  in 
the  sequence  of  acute  intestinal  catarrh  if  this  be  frequently  re- 


CHRONIC  INTESTINAL  CATARRH  253 

peated,  and  especially  if  recurrence  take  place  after  incomplete 
recovery  from  the  preceding  attack.  At  other  times  it  develops 
as  an  independent  affection,  and  under  such  circumstances  definite 
causes  will  be  found  to  have  been  operative.  HypostatiG  catarrh 
exhibits  a  marked  tendency  to  pursue  a  chronic  course.  It  may 
be  induced  by  the  general  stasis  attending  chronic  disease  of  the 
heart  or  of  the  respiratory  apparatus,  or  it  may  develop  as  a  result 
of  stasis  in  the  portal  circulation,  and  most  commonly  in  associa- 
tion with  cirrhosis  of  the  liver.  Chronic  debilitating  disease,  as, 
for  instance,  pulmonary  tuberculosis,  carcinoma,  leukemia,  pro- 
tracted suppuration,  often  maintains  chronic  intestinal  catarrh. 
Not  rarely  chronic  intestinal  diseases  (carcinoma,  hemorrhoids, 
tuberculous  ulceration,  parasites)  are  accompanied  by  chronic 
intestinal  catarrh.  Chronic  constipation  is  often  a  cause  of 
chronic  intestinal  catarrh. 

Anatomic  Alterations. — Intestinal  mucous  membrane  the 
seat  of  chronic  inflammation  is  conspicuous  for  its  color.  It  is 
brownish-red  or  grayish-red  in  appearance,  especially  on  the  villi 
and  at  the  summit  of  its  folds.  At  times  the  brownish  hemo- 
globin has  been  transformed  into  black  melanin,  so  that  the 
mucous  membrane  presents  a  mottled  appearance — so-called  vil- 
lous melanosis.  Besides,  the  presence  of  excessive  secretion  is 
conspicuous,  the  mucous  membrane  being  covered  with  trans- 
parent or  slightly  turbid  mucus.  The  lymph-follicles  are  often 
enlarged,  and  surrounded  by  a  brownish  or  blackish  zone  of  pig- 
ment. As  a  rule,  the  mucous  membrane  is  thickened  in  conse- 
quence of  inflammatory  hyperplasia  of  the  connective  tissue,  and 
often  the  muscularis  and  the  mucosa  also  participate  in  the  hyper- 
plasia and  thickening.  Under  such  circumstances  the  condition 
can  be  designated  hypertrophic  chronic  gastric  catarrh.  In  con- 
tradistinction from  this,  atrophic  chronic  gastric  catarrh  is  attended 
with  abnormal  attenuation  of  the  intestinal  wall,  together  with 
atrophy  of  the  glandular  layer  of  the  mucous  membrane.  Further, 
especial  care  should  be  taken  in  reaching  a  decision  as  to  the  ex- 
istence of  chronic  atrophic  intestinal  catarrh,  as  frequently  the 
condition  of  intestinal  atrophy  is  simulated  by  insignificant  post- 
mortem alterations.  Among  the  complications  of  chronic  intes- 
tinal catarrh  catan^hal  ulceration  of  the  bowel  may  be  mentioned, 
which  may  have  resulted  from  disintegration  of  lymph-follicles — 
follicular  intestinal  ulceration — or  from  destruction  of  the  tissue 
of  the  mucosa  itself — catarrhal  ulceration  of  the  mucous  membrane. 

Among  rarer  occurrences  polypoid  hyperplasia  of  the  mucous  membrane 
and  cystic  degeneration  of  the  glands  of  the  intestinal  mucous  membrane  may 
be  mentioned. 

Symptoms  and  Diagnosis. — Alterations  in  the  stools  con- 
stitute the  main  symptom  of  chronic  intestinal   catarrh.     As  a 


254  DIGESTIVE  ORGANS 

rule,  there  is  irregularity  in  the  movement  of  the  bowels,  and 
often  constipation  and  diarrhea  alternate  with  each  other.  The 
abundant  presence  of  mucus  in  the  stools  is  distinctive.  In  the 
presence  of  catarrh  of  the  large  intestine  the  individual  fecal 
masses  are  often  enclosed  in  a  layer  of  mucus.  In  the  presence 
of  catarrh  of  the  small  intestine,  on  the  other  hand,  there  is 
intimate  admixture  of  fecal  matter.  Often  the  stools  are  stained 
yellow  by  biliary  coloring-matter,  and  on  addition  of  nitric  acid 
they  yield  the  reaction  of  biliary  coloring-matter.  At  times 
peculiar,  swollen  and  transparent,  sago-like  granules  are  present 
in  the  stools,  which  consist  in  part  of  swollen  carbohydrates  and 
in  part  of  mucus.  These  were  formerly  considered  erroneously  as 
distinctive  of  follicular  ulceration  of  the  bowel.  The  stools  at 
times  contain  a  strikingly  large  amount  of  undigested  food.  If 
this  be  recognizable  with  the  unaided  eye,  the  condition  has  been 
designated  lientery.  Microscopic  examination  of  the  stools  dis- 
closes, in  addition  to  remnants  of  food  and  bacteria,  isolated 
round  cells  and  epithelial  cells.  The  latter  are  often  peculiarly 
swollen,  and,  in  the  presence  of  catarrh  of  the  small  intestine, 
bile-stained. 

Rumbling  in  the  abdomen — borborygmi,  distention  of  the  abdo- 
men— intestinal  meteorism,  and  abdominal  pain — tormina — are  fre- 
quently recurring  symptoms,  which  at  times  become  particularly 
severe.  Chronic  intestinal  catarrh  is  usually  unattended  with 
fever.  Nutrition  may  suffer  in  marked  degree.  The  patients 
emaciate  progressively,  and  acquire  a  grayish  and  sallow  appear- 
ance. Psychic  alterations  occur  with  especial  frequency,  and 
they  have  not  improperly  been  explained  as  the  results  of  auto- 
intoxication, inasmuch  as  abnormal  metabolic  products  are  ab- 
sorbed from  the  intestine  and  derange  the  functions  of  the 
nervous  system.  The  patients  become  hypochondriacal,  believe 
themselves  to  be  suffering  from  all  possible  serious  diseases, 
develop  a  fear  that  they  will  become  insane,  are  involved  in 
doubts  as  to  their  mental  and  physical  ability,  and  complain  of 
all  possible  conditions  of  fear.  They  are  often  troubled  by 
annoying  vertigo — intestinal  vertigo,  which  can  at  times  be  devel- 
oped voluntarily  by  pressure  upon  the  bowel.  Palpitation  of  the 
heart  and  asthmatic  states  also  occur  occasionally.  The  appetite 
is  variable,  and  is  impaired  especially  when  the  stomach  is  also 
involved  in  the  inflammatory  process.  Thirst  is  usually  increased. 
The  urine  is  usually  voided  in  small  amount,  is  therefore  gen- 
erally characterized  by  its  dark-rod  color,  and  frequently  precipi- 
tates a  reddish,  granular  sediment  of  urates. 

The  duration  of  chronic  intestincd  catarrh  is  subject  to  Avide 
variations.  In  some  individuals  it  persists  throughout  life.  If 
ulceration  of  the  intestinal  mucous  membrane  has  taken  place, 
hemorrhage,  rupture,  and,  after  cicatrization  of  ulcers,  stenosis  of 


CHRONIC  INTESTINAL  CATARRH  255 

the  bowel  may  occur  as  complications,  but  these  occurrences  are 
rare.  Most  commonly  chronic  inflammation  of  the  bowel  in- 
volves the  ileum  and  the  colon,  in  correspondence  with  the  like  con- 
ditions that  attend  acute  intestinal  catarrh,  and  what  has  been  said 
in  the  preceding  refers  principally  to  chronic  catarrhal  ileocolitis. 

Chronic  catarrhal  duodenitis  is  characterized  by  involvement 
of  the  choledoch  duct  and  chronic  catarrhal  jaundice.  Chronic 
inflammation  of  the  rectum — chronic  catarrhal  proctitis — like  acute 
proctitis,  is  attended  witlv  a  persistent  desire  for  stool — anal  tenes- 
mus. The  stools  at  times  consist  only  of  mucus  or  of  mucus  and 
pus.  Sometimes  the  structures  surrounding  the  rectum  become 
involved  in  the  inflammatory  process — periproctitis;  and  if  a  col- 
lection of  pus  in  this  situation  ruptures  outward  or  inward,  or  in 
both  directions  simultaneously,  an  external  or  an  internal  or  a 
complete  rectal  fistida  will  result. 

Prominence  should  be  given  to  that  form  of  colitis  which  has 
been  designated  membranous  enteritis — mucous  colic.  This  is 
characterized  generally  by  the  periodic  evacuation  of  whitish 
membranes,  tubes,  and  shreds,  consisting  of  mucus,  and  less 
commonly  of  fibrin  and  all)uminoid  material,  and  which  have 
collected  along  the  bands  of  the  colon.  The  evacuations  are 
usually  preceded  by  disagreeable  sensations  in  the  abdomen,  with 
distention,  and  the  expulsion  of  the  sometimes  long  casts  is 
attended  with  severe  pain  and  difficulty.  Care  should  be  taken, 
further,  to  avoid  confounding  such  casts  with  tendinous  struct- 
ures, the  fibrous  remains  of  asparagus,  and  the  like,  and  this  can 
readily  be  done  by  microscopic  examination.  The  membranes 
and  tubes  exhibit  under  the  microscope  a  swollen  structure,  which 
becomes  striated  on  addition  of  acetic  acid,  and  contains  epithelial 
cells,  isolated  round  cells,  and  crystals  of  triple  phosphate  and 
cholesterin.  This  condition  occurs  principally  in  nervous  indi- 
viduals, particularly  women,  and  while  not  dangerous  is  often 
very  obstinate.  Only  in  the  minority  of  cases  does  the  condition 
appear  to  be  the  sequel  of  chronic  intestinal  catarrh — true  mem- 
branous enteritis ;  while  in  the  majority  of  cases  it  appears  to  be  a 
secretory  neurosis  of  the  intestinal  mucous  membrane — mucous  colic. 

The  occurrence  in  children  suffering  from  chronic  intestinal 
catarrh  of  stools  containing  considerable  fat  has  been  described  as 
fatty  diarrhea,  the  absorption  of  fat  being  obviously  much  dimin- 
ished. The  stools  present  a  yellowish  or  grayish  appearance,  give 
off*  an  odor  of  fatty  acids,  when  rubbed  up  with  water  and  ex- 
amined microscopically  exhibit  an  abundance  of  fat-globules,  and 
on  analysis  are  found  to  contain  67  per  cent,  instead  of  20  per  cent, 
of  fat.  The  condition  is  observed  especially  in  association  with 
catarrh  of  the  small  intestine,  and  also  when  the  pancreas  is  dis- 
eased and  the  discharge  of  bile  into  the  intestine  is  interfered  with. 

PrognosiS.^Although  chronic  intestinal  catarrh  is  as  a  rule 


256       ^  DIGESTIVE  ORGANS 

not  a  dangerous  disorder,  it  is  often  extremely  obstinate  and  annoy- 
ing. At  times  the  prognosis  is  unfavorable,  because  the  causative 
conditions  (carcinoma,  tuberculosis)  are  incurable. 

Treatment. — In  the  treatment  of  chronic  intestinal  catarrh 
consideration  should  first  be  given  to  the  causative  conditions, 
and  an  elibrt  made  to  relieve  them — causal  therapy.  Symptomatic 
treatment  will  have  to  be  directed  most  frequently  to  the  relief  of 
existing  constipation.  The  mode  of  life  and  the  diet  will  next 
require  correction.  The  patients  should  take  Avalks  regularly, 
indulge  in  gymnastic  exercises  and  physical  activity,  and  never 
suppress  the  desire  for  stool,  however  slight  this  may  be  (a  rule 
that  must  be  especially  impressed  upon  women),  while  a  daily 
eifort  to  evacuate  the  bowel  at  the  same  time  should  be  encour- 
aged, even  in  the  absence  of  the  normal  desire,  in  order  to  accus- 
tom the  bowel  to  habitual  activity.  The  diet  should  include  such 
articles  of  food  as  experience  has  shown  to  be  capable  of  stimu- 
lating the  bowels  to  increased  activity.  Among  these  may  be 
mentioned  Graham  bread  witli  butter  and  honey  in  the  morning, 
Graham  bread  with  butter  in  the  evening,  fruit  at  noon  and  in 
the  evening,  and  vegetables  at  noon.  Often  the  patients  have 
themselves  discovered  certain  domestic  remedies  capable  of  induc- 
ing movement  of  the  bowels,  as,  for  instance,  the  ingestion  of  a 
glass  of  cold  water  when  the  stomach  is  empty,  or  the  smoking 
of  a  cigar.  Among  medicaments,  laxatives,  mineral  waters,  and 
enemata  may  be  mentioned.  It  should  be  pointed  out  that  the 
intestine  readily  becomes  accustomed  to  a  given  medicament  or 
procedure,  so  that  variation  is  necessary  from  time  to  time. 
Among  laxatives,  rhubarb-root,  senna-leaves,  aloes,  jalap,  and 
podophyllin  particularly  may  be  recommended ;  as,  for  instance  : 

R  Aloes, 

Compound  extract  of  rhubarb,         each,  1.5  (22J  grains) ; 

Powder  and  fluid  extract  of  licorice,  sufficient  to  make  30  pills. 
Dose:  1  or  2  pills  at  night. 

B  Aloes, 

Compound  extract  of  rhubarb, 

Powdered  jalap,  each,  1.0  (15  grains) ; 

Powder  and  fluid  extract  of  licorice,  sufficient  to  make  30  pills. 
Dose :  From  1  to  3  pills  at  night. 

R  Aloes, 

Compound  extract  of  rhubarb,        each,  1.5  (22.1  grains); 

Podophyllin,  0.3  (  4.}       "     ) ;    . 

Powder  and  fluid  extract  of  licorice,  sufficient  to  make  30  pills. 
Dose :  1  or  2  pills  at  night. 

R  Compound  licorice-powder,  100.0  (3  ounces). 

Dose:  1  or  2  teaspoonfuls  in  a  wine-glassful  of  tepid  water  in  the 
morning. 

R  Electuary  of  senna,  50.0  (1^  ounces). 

Dose :  1  teaspoonful  in  the  morning. 


INFLAMMATION  OF  CECUM  AND  VERMIFORM  APPENDIX.     257 

Among  mineral  waters  may  be  mentioned  the  various  bitter 
waters  (Ofen,  Pullna,  Saidschutz,  Friedrichshall,  Birraenstorf, 
Baden),  of  which  one  or  two  wine-glassfids  should  be  taken  in  the 
morning  when  the  stomach  is  empty,  to  be  followed  in  a  short 
time  by  an  equal  quantity  of  cold  water.  Carlsbad  salt  (solution 
of  artificial  Carlsbad  salt — 1  or  2  teaspoonfuls  to  a  glass  of  water 
when  the  stomach  is  empty)  is  often  employed  with  success. 
Enemata  may  be  administered  advantageously  in  the  form  of 
intestinal  infusions.  For  this  purpose  either  an  irrigator  with  a 
tube  and  a  rectal  nozzle,  or  the  funnel-apparatus  of  Hegar,  con- 
sisting of  a  large  glass  funnel  with  a  rubber  tube  and  rectal  nozzle,, 
is  employed.  The  irrigating  fluid  should  be  water  at  room-tem- 
perature, and  from  1  to  2  liters  should  be  permitted  to  flow  into 
the  large  intestine.  The  introduction  is  best  effected  with  the 
pelvis  elevated,  and  even  more  satisfactorily  in  the  knee-elbow 
posture.  Frequently  the  water  will  not  flow  because  the  rubber 
tube  is  filled  with  air.  This  can  be  removed  readily  by  repeated 
and  vigorous  pressure  with  the  fingers  upon  the  tube.  Russian 
physicians  were  the  first  to  recommend  large  enemata  of  oil  for 
the  relief  of  obstinate  constipation  (from  400  to  500  c.c.  of  poppy- 
seed  oil — about  1  pint — to  each  enema).  Glycerin-enemata  are 
also  highly  efficacious  (2.0 — 30  minims — glycerin  to  each  enema), 
while  glycerin-suppositories  are  less  reliable  in  action.  Well-to- 
do  patients  may  during  the  summer  undertake  courses  of  treat- 
ment at  the  springs.  Among  these,  the  springs  of  Carlsbad, 
Marienbad,  Tarasp,  Kissingen,  Homburg,  Ems,  Wiesbaden,  and 
Vichy  especially  should  be  mentioned.  In  cases  of  chronic  duo- 
denitis loith  jaundice  all  articles  of  food  containing  fat  should  be 
interdicted.  Membranous  enteritis  is  often  resistant  to  all  forms 
of  treatment.  In  the  first  place,  the  nervous  general  condition 
should  be  taken  into  consideration,  and  in  addition  intestinal  infu- 
sions of  oil,  water,  and  astringents  should  be  employed. 

INFLAMMATION  OF  THE  CECUM  AND  THE  VER- 
MIFORM APPENDIX  AND  THE  SURROUNDING 
TISSUES  (TYPHLITIS;  APPENDICITIS;  PERITYPH- 
LITIS; PARATYPHLITIS)* 

Btiology  and  Anatomic  Alterations. — Inflammatory 
processes  not  rarely  occur  in  the  right  iliac  fossa,  which  have 
certain  important  symptoms  in  common  (usually  sudden  onset, 
pain,  and  acute  tumor-formation).  Inflammation  of  the  cecum  is 
known  as  typhlitis,  while  inflammation  of  the  vermiform  process 
is  designated  appendicitis.  Circumscribed  inflammation  of  the 
peritoneal  covering  of  the  cecum  or  the  vermiform  process  is 
luiown  2ii^  perityphlitis.  Inflammation  of  the  retrocecal  connective 
tissue,  by  which  the  vermiform  appendix  is  attaclied  to  the  iliac 
17 


258  DIGESTIVE  ORGANS 

fossa,  is  known  as  paratyphlitk.  Typhlitis  and  ap})enclicitis  are 
almost  always  independent  diseases,  while  perityphlitis  and  para- 
typhlitis are  usually  of  secondary  origin,  and  most  commonly 
result  from  preceding  appendicitis  or  typhlitis.  Appendicitis  and 
peril i/phlitis  are  the  conditions  most  commonly  encountered.  In 
the  majority  of  cases  the  process  pursues  the  following  course : 
Fecal  matter  becomes  lodged  in  the  vermiform  appendix,  and  in 
consequence  of  desiccation  becomes  solidified  into  so-called  false 
fecal  concretions,  which  after  a  while  cause  mechanical  irritation 
of  the  walls  of  the  appendix,  with  secondary  inflammation  and 
necrosis.  The  inflammatory  process  readily  extends  to  the  adja- 
cent peritoneum,  so  that  to  appendicitis  is  superadded  perityphlitis. 
The  latter  frequently  occurs  from  perforation  of  the  walls  of  the 
appendix  by  a  fecal  concretion,  which  may  become  lodged  in  the 
orifice  of  perforation  or  is  expelled  into  the  peritoneal  cavity. 
At  times  the  free  extremity  of  the  vermiform  process  is  detached 
in  its  circumference,  the  stone  occupying  the  mouth  of  the  ap- 
pendix. Perityphlitis  usually  gives  rise  to  the  formation  of  an 
encapsulated,  purulent  exudate,  which  may  acquire  a  fecal  odor 
even  if  perforation  of  the  bowel  has  not  taken  place.  After  peri- 
typhlitis has  existed  for  a  considerable  length  of  time  adhesions 
are  usually  so  numerous  that  it  is  difficult  to  find  the  appendix 
at  all,  not  to  speak  of  the  point  of  perforation  and  a  fecal  con- 
cretion. 

Clinical  experience  has  shown  that  the  tendency  to  the  forma- 
tion of  fecal  calculi,  and  therefore  also  to  appendicitis  and  peri- 
typhlitis, is  unevenly  distributed.  In  some  families  the  disease 
occurs  with  such  remarkable  frequency  that  the  causative  factors 
have  been  looked  for  in  some  anatomic  peculiarity  of  tlie  vermiform 
appendix  (excessive  length,  undue  development  of  Gerlach's  valve 
at  the  entrance  to  the  vermiform  appendix,  unusual  size).  Without 
doubt  the  character  of  the  food  has  an  influence  upon  the  forma- 
tion of  fecal  concretions,  as  these  are  observed  most  commonly  in 
individuals  who  live  excessively  upon  a  vegetable  diet.  The 
swallowing  of  foreign  bodies  is  also  a  dangerous  practice  in  this 
connection.  Thus,  I  have  observed  fecal  concretions  formed  about 
swallowed  hair  from  the  beard  and  bristles  from  the  tooth-brush. 
A  sedentary  mode  of  life  predisposes  in  marked  degree  to  the 
formation  of  fecal  concretions  and  their  consequences;  so  does 
also  constipation. 

As  several  of  the  causative  factors  named  are  ojjerative  in  the 
individuals  concerned  throughout  life,  it  can  be  readily  understood 
that  appendicitis  and  perityphlitis  are  frequently  recurrent.  Atten- 
tion has  recently  been  called  to  the  foct  that  inflammatory  condi- 
tions (catarrhal j  hemorrhagic,  purulent,  gangrenous)  of  the  mucous 
membrane  of  the  vermiform  process  are  not  uncommon,  and  that 
these  also  may  be  followed  by  the  formation  of  fecal  concretions, 


INFLAMMATION  OF  CECUM  AND  VERMIFORM  APPENDIX.     259 

appendicitis,  and  perityphlitis.  True  fecal  concretions  constitute 
much  less  commonly  than  false  fecal  concretions  the  starting-point 
for  inflammation  of  the  vermiform  appendix  and  its  vicinity.  True 
fecal  concretions  consist  of  mineral  deposits,  whose  princijial  con- 
stituents are  generally  calcium  phosphate,  calcium  carbonate,  and 
ammonio-magnesium  phosphate.  At  times  swallowed  foreign  bodies 
give  rise  to  appendicitis  and  perityphlitis.  Thus,  a  railway-official 
under  my  care  died  with  pyemic  manifestations  in  the  sequence 
of  appendicitis  and  perityphlitis,  w^ho  attributed  his  disease  to 
the  sharp  fragment  of  a  tooth-pick  that  he  had  swallowed.  It 
should  not  be  forgotten  that  at  times  ulceration  of  the  mucous 
membrane  of  the  vermiform  appendix  (catarrhal,  typhoid,  tuber- 
culous, carcinomatous,  actinomycotic)  may  be  followed  by  appen- 
dicitis. Not  rarely  traumatism,  exposure  to  cold,  and,  in  my 
experience,  with  especial  frequency,  the  ingestion  of  cold  fluids 
(beer)  are  named  as  causes  of  the  disease,  but  these  influences 
probably  play  the  rd/e  rather  of  contributory  factors,  which  fur- 
nish the  final  impulse  for  the  outbreak  of  the  disorder,  long  after 
the  true  germ  had  been  present. 

Although  appendicitis  is  the  most  common  cause  for  perityphlitis, 
it  is  by  no  means  the  sole  cause.  Perityphlitis  may,  for  instance, 
be  dependent  upon  a  preceding  typhlitis.  At  times  it  originates 
from  a  perimetritis,  a  salpingitis,  or  an  oophoritis,  and  it  may  happen 
that  the  exudate  has  already  disappeared  from  the  actual  starting- 
point  of  the  inflammation,  and  an  apparently  primary  perityphlitis 
is  encountered.  In  women  it  is,  therefore,  not  uncommon  for  the 
manifestations  of  perityphlitis  to  appear  in  the  sequence  of  menstrual 
disturbances.  Constipation  was  formerly  considered  the  cause  of 
inflammation  of  the  cecum  (typhlitis),  and  the  condition  was,  accord- 
ingly designated  stercoral  typhlitis.  Stagnation  of  fecal  matter  may 
readily  take  place  in  the  cecum,  because  here  the  intestinal  con- 
tents become  inspissated,  and  to  a  certain  degree  must  be  propelled 
against  the  force  of  gravity.  A  sedentary  mode  of  life  and  ex- 
cessive use  of  vegetables,  as  well  as  swallowed  foreign  bodies,  will 
favor  fecal  stagnation.  Kecently  attempts  have  been  made  to  cast 
doubt  upon  the  occurrence  of  stercoral  typhlitis,  but  upon  the 
basis  of  personal  experience  it  appears  to  me  that  they  have  not 
succeeded.  Ulcerative  processes  may  induce  inflammation  in  the 
cecum  in  the  same  manner  as  in  the  vermiform  process.  Trau- 
matism is  at  times  followed  by  typhlitis. 

Paratyphlitis  may  arise  by  extension  from  typhlitis  or  peri- 
typlitis,  or  it  may  develop  in  the  sequence  of  paranephritis,  para- 
metritis, periproctitis,  psoas-abscess,  inflammation  of  the  innominate 
bone  or  of  the  vertebral  column,  when  the  inflammatory  process 
extends  to  the  iliac  fossa  or  gives  rise  to  burrowing  abscesses 
therein.  As  in  perityplitis,  so  also  in  paratyphlitis  it  may  happen 
that  the  exudate  at  the  site  of  primary  inflammation  has  been 


260  DIGESTIVE  ORGANS 

absorbed,  leaving  a  paratyphlitis.  At  times  paratyphlitis  develops 
in  the  sequence  of  infectious  diseases  (typhoid  fever,  septicemia). 
Trauiiiafic  paratt/pJtlitis  may  occur  as  an  independent  disorder, 
as  after  the  lifting  of  lieavy  weights,  after  over-exertion  in  the 
process  of  washing  and  tlie  hanging  up  of  linen,  and  in  some 
persons  it  may  be  recurrent.  The  occurrence  of  refrigeratory 
{rheiimntic)  paratyphlitis  may  properly  be  doubted. 

The  inflammatory  processes  under  consideration  may  develop  at 
any  period  of  life,  though  most  commonly  between  the  sixteenth  and 
the  twenty-fifth  year,  and  the  impression  has  been  created  that  their 
frequency  has  become  progressively  greater  witliin  recent  times. 
Men  are  attacked,  experience  has  shown,  more  than  twice  as  often 
as  women. 

Symptoms. — Appendicitis  and  pcritypjhlitis  frequently  set  in 
with  sudden,  sharp  pain  in  the  right  iliac  fossa,  the  intensity  of 
which  is  often  so  great  that  the  patients  will  not  tolerate  the  slight- 
est pressure  with  the  fingers,  not  even  that  of  a  light  sheet.  The 
abdomen  is  generally  distended,  obviously  because  a  large  amount 
of  gas  has  accumulated  in  the  small  intestine.  Often  a  con- 
siderable prominence  is  noticeable  in  the  right  iUac  fossa.  On  pal- 
pation, which  naturally  should  be  practised  with  great  care,  only 
increased  tension  of  the  abdominal  walls  and  increased  resistance 
without  sharp  limitation,  may  at  first  be  appreciated.  In  the 
course  of  a  few  days  at  most,  a  readily  circumscribed  tumor  will 
have  formed  in  the  right  iliac  fossa.  The  most  common  variety 
of  tumor  begins  below  at  about  the  middle  of  Poupart's  ligament, 
forming  a  convex  arch  toward  the  median  line  of  the  al)domen 
and  disappearing  on  the  right  side  of  the  abdomen  below  the 
lower  margin  of  the  liver.  The  right  lumbar  region  also  is  fre- 
quently distinctly  resistant.  Xot  rarely  the  tumor  is  smaller  in 
extent.     Palpable  exudates  of  band-like  shape  also  occur. 

In  addition  to  the  local  abdominal  alterations  there  are  usually 
disturbances  of  gastric  and  intestinal  activity.  Vomiting  is  an  ex- 
ceedingly frequent  manifestation.  The  vomited  matters  consist  at 
first  of  gastric  contents,  but  after  emesis  has  persisted  for  some 
time  they  assume  a  bilious  character,  and  present  at  times  a  yel- 
lowish, and  at  other  times  a  greenish  color.  Eructation — singultus 
— is  one  of  the  common  symptoms.  Appetite  is  entirely  M'anting, 
while  thirst  is  greatly  increased.  The  tongue  is  almost  always 
coated.  Often  the  breath  is  extremely  offensive.  The  bowels  are 
usually  constipated,  although  at  the  beginning  of  the  attack  a  few 
thin  bowel-movements  may  be  passed.  The  urine  constantly  con- 
tains an  increased  amount  of  indican  in  consequence  of  derange- 
ment of  digestive  activity  in  the  small  intestine  and  increased 
proteid  decomposition  in  the  bowel.  The  urine  is  at  the  same 
time  passed  in  small  amount,  and  consequently  is  generally  dark 
red  in  color.     Appendicitis  and  perityphlitis  are  almost  always 


INFLAMMATION  OF  CECUM  AND  VERMIF0B3I  APPENDIX    261 

attended  -svith  fever;  a  perfectly  afebrile  course  is  exceptional. 
The  elevation  of  teniperature  may  reach  39°  C.  (102.2°  F.)  or  40° 
C.  (104°  F.).  The  fever  pursues  no  definite  type,  and  declines 
gradually  after  a  variable  period  of  time.  The  patients  usually 
occupy  a  peculiarly  rigid  posture,  lying  upon  the  back,  as  a  rule 
somewhat  inclined  toward  the  right,  and  as  much  as  possible 
avoiding  all  change  in  position  on  account  of  the  resulting  severe 
abdominal  pain. 

The  duration  of  an  attack  of  appendicitis  and  jjeritypliUtis  is 
extremely  variable,  and  fluctuates  between  days,  weeks,  and 
months.  In  the  natural  course  of  the  disease  the  fever  disappears 
slowly,  the  pains  beccmie  less  severe,  the  exudate  becomes  smaller, 
harder,  and  more  sharply  circumscribed.  Painless  residues  of 
exudate  and  infiltrations  in  the  right  iliac  fossa  often  persist  for 
many  months.  Frequently  it  is  remarkable  how  after  a  copious 
evacuation  of  the  bowels  the  exudate  becomes  almost  suddenly 
smaller,  obviously  because  the  accumulated  fecal  matter  has  arti- 
ficially increased  the  extent  of  the  exudate.  Often  sharp  pain 
and  tenderness  in  the  right  iliac  fossa  persist  for  a  long  time. 

Dropsy  of  the  vermiform  process  develops  at  times  as  a  sequel  of  appen- 
dicitis, and  it  may  be  represented  by  a  smooth  and  movable  tumor  as  big  as 
a  fist.  A  similar  condition  may  develop  when  ulcers,  and  subsequently 
cicatrices,  form  in  the  neighborhood  of  the  entrance  to  the  vermiform 
appendix,  and  these  give  rise  to  occlusion  of  the  appendix.  Mucoid 
masses  then  accumulate  in  the  appendix  with  increasing  distention. 

Among  the  complications,  one  of  the  most  dangerous  is  diffuse 
acute  peritonitis,  which  may  be  readily  recognized  from  the  exten- 
sive tenderness  of  -the  abdominal  walls,  the  increased  distention 
of  the  abdomen,  and  the  aggravation  of  the  general  condition.  At 
times  incautious  bodily  movement  or  dietetic  error  may  be  found 
to  be  a  causative  factor.  Improper  manipulation  of  the  abdominal 
walls  also  may  give  rise  to  diffuse  peritonitis,  an  encapsulated 
peritiphlytic  exudate  rupturing  into  the  abdominal  cavity.  Con- 
stipation and  expulsive  efforts  at  stool  may  likewise  give  rise  to 
general  peritonitis.  Pneumoperitonitis  develops  "when  in  addition 
to  fecal  matter  air  also  enters  the  abdominal  cavity  through  a 
perforation  in  the  vermiform  appendix.  The  principal  distinctive 
features  of  this  condition  consist  in  marked  abdominal  distention, 
abdominal  tenderness,  absence  of  hepatic  and  splenic  percussiori- 
dulness,  and  general  collapse.  At  times  symptoms  of  ileus  appear 
(fecal  vomiting,  constipation,  and  absence  of  flatus)  without  a  me- 
chanical obstruction  of  the  intestine  being  demonstrable  at  autopsy. 
Under  such  circumstances  the  condition  is  probably  one  of 
dynamic  or  paralytic  ileus  resulting  from  partial  paralysis  of  the 
muscular  coat  of  the  bowel.  Some  patients  complain  of  dysuria, 
which  is  probably  dependent  upon  perityphlitis,  and  it  may  be- 
come  necessarv  to  remove  the  urine  with  the  aid  of  a  catheter. 


2G2  DRiEHTIVE  ORGANS 

I  have  observed  the  iwine  to  be  alkaline  for  days  with  particular 
frequency  whcu  absorption  of  the  exudate  has  set  in.  Pleurisy 
develops  in  about  one-third  of  the  cases.  Most  commonly  it  is 
right-sided,  althougii  it  may  be  left-sided  or  bilateral.  Usually 
it  is  serous  in  character.  Often  it  is  absorbed  with  marked  rapid- 
ity. Among  the  complications  rupture  of  the  pus  may  yet  be 
mentioned.  This  may  take  place  into  the  intestine,  and  its  occur- 
rence can  be  recognized  from  the  presence  of  pus  in  the  stools. 
I  have  on  several  occasions  also  observed  a  desire  for  stool  and 
pain  during  evacuation  of  the  bowels — tenesmus  ani.  In  other 
instances  the  pus  ruptures  into  the  urinary  ])assages  (pelvis  of  the 
kidney,  ureter,  bladder),  and  pyuria  and  dysuria  develop.  Rup- 
ture into  the  uterus  or  the  vagina  is  also  conceivable.  At  times 
the  pus  burrows  beneath  the  cutaneous  integument.  Redness 
and  doughy  induration  of  the  skin,  increasing  prominence  and 
fluctuation  of  progressively  increasing  distinctness  are  indicative 
of  the  advent  of  this  condition.  The  point  of  rupture  is  at 
times  in  the  neighborhood  of  the  right  iliac  fossa  itself,  but  at 
other  times  in  consequence  of  burrowing  it  may  be  situated  at  a 
remote  point,  as,  for  instance,  at  the  umbilicus,  below  Poupart's 
ligament,  etc. 

Occasionally  subphrenic  pyothoj^ax,  or  pyopneumothwax — that 
is,  an  accumulation  of  pus  or  of  pus  and  air  between  the  diaphragm 
and  the  upper  surface  of  tlie  liver — has  been  observed  to  develop 
in  the  sequence  of  perityphlitis.  At  times  appendicitis  and  peri- 
typhlitis give  rise  to  septicopyemia,  jiurulent  thrombi  foi'ming  in 
the  mesenteric  veins,  from  which  emboli  may  be  detached  and  be 
swept  into  the  circulation,  giving  rise  especially  to  multiple  abscess 
of  the  liver.  In  one  case  I  observed  such  a  condition  develop 
seventeen  years  after  an  attack  of  acute  appendicitis. 

Stercoral  typhlitis  usually  occurs  after  preexisting  constipation. 
The  patient  complains  suddenly  of  pain  in  the  right  iliac  fossa,  and 
in  this  situation  is  found  a  painful  tumor,  which,  in  contradistinc- 
tion from  a  perityphlitic  exudate,  yields  a  dull,  and  not  a  dull- 
tym))anitic  note  upon  percussion,  and  does  not  extend  to  the 
median  line  of  the  abdomen  and  upward  to  the  lower  margin  of 
the  liver,  but  which  at  times,  when  marked  pressure  is  made  with 
the  finger,  presents  depressions  due  to  indentations  of  the  fecal 
fnatter.  It  is  further  distinctive  that  after  a  copious  evacuation  of 
tiie  bowels  the  timior  usually  disajijicars,  and  at  most  slight  indu- 
ration remains  for  a  short  time,  which  may  possibly  be  dependent 
upon  inflammatory  swelling  of  the  intestinal  mucous  membrane. 
The  abdomen  is  intensely  distended,  in  consequence  of  fecal  stag- 
nation and  abundant  generation  of  gas.  There  is  no  increase  in  the 
amount  of  indiean  in  the  urine,  or  this  is  but  slight.  Febrile  move- 
ment also  is  wanting,  or  is  not  marked.  As  a  rule,  a  rapid  change 
for  the  better  occurs  when  a  copious  bowel-movement  lias  been 


INFLAMMATION  OF  CECUM  AND  VERMIFORM  APPENDIX    263 

induced ;  otherwise,  naturally,  serious  dangers  may  arise,  among 
which  may  be  mentioned  ileus,  perityphlitis,  peritonitiH,  and  rupture 
of  the  bowel. 

Paratyphlitis  also  is  attended  with  pain  and  tumor-formation  in 
the  right  iliac  fossa,  but  the  tumor  is  not  so  superficial  as  in  the 
case  of  perityphlitis  and  typhlitis,  and  it  is  concealed  by  the  tym- 
panitic percussion-note  yielded  by  the  cecum.  The  amount  of 
indican  in  the  urine  is  not  increased.  Fever  is  present,  and  the 
patient  usually  keeps  the  right  thigh  flexed,  probably  in  conse- 
quence of  involvement  of  the  iliopsoas.  At  times  unyielding 
muscular  contractures  develop.  Occasionally  pressure  exerted  by 
the  exudate  upon  the  nerves  to  the  extremity  passing  through  the 
pelvis  gives  rise  to  paresthesia,  neuralgia,  and  paralytic  conditions 
in  the  right  leg.  Pain  in  the  right  testicle  and  spasmodic  elevation 
of  this  organ  have  been  observed.  Pressure  of  the  exudate  upon 
the  veins  of  the  extremities  may  give  rise  to  edema  in  these  parts. 
The  disease  is  not  unattended  with  dangers  and  other  complica- 
tions. Thus,  general  septicopyemia  may  develop,  or  the  pus  may 
rupture  into  the  intestine,  the  urinary  pas-sages,  the  peritoneal 
cavity,  or  externally.  In  the  last-named  event  extensive  bur- 
rowing of  the  pus  may  take  place,  as,  for  example,  down  into  the 
extremities,  the  perineum,  the  vagina.  In  one  case  I  observed 
rupture  of  the  pus  upon  the  left  side  of  the  abdomen.  It  may 
also  occur  that  the  pus  in  the  right  iliac  fossa  has  been  absorbed, 
and  that  suppuration  is  present  only  at  the  most  dependent  point. 
In  this  way  paratyphlitis  may  be  transformed  into  paranephritis, 
parametritis,  or  periproctitis.  Rupture  of  the  pus  into  the  peri- 
toneal cavity  is  particularly  dangerous,  as  it  is  usually  followed  by 
fatal  peritonitis.  After  rupture  of  the  pus  into  the  bladder  or  the 
bowel  recovery  not  rarely  takes  place,  because  the  fistula  is  so  con- 
stituted that  while  it  permits  the  escape  of  pus  it  prevents  the 
access  of  urine  or  feces  to  the  inflammatory  focus,  with  the  devel- 
opment in  it  of  putrefaction.  At  times  perityphlitis  is  superadded 
to  paratyphlitis  without  preceding  rupture  of  the  pus.  Paratyph- 
litis frequently  pursues  a  chronic  course,  and  the  patient  at  times 
dies  from  progressive  exhaustion. 

Diagnosis. — With  regard  to  the  diflerentiation  between 
appendicitis,  perityphlitis,  paratyphlitis,  and  typhlitis  the  essen- 
tial facts  have  already  been  stated.  Attention  should,  further,  be 
directed  to  the  circumstance  that  these  diseases  may  at  times  be 
confounded  with  other  disorders.  Carcinoma  of  the  cecum  usually 
occurs  in  old  persons,  gives  rise  to  the  development  of  a  nodular 
tumor,  induces  rapid  marasmus,  begins  insidiously,  and  pursues  a 
chronic  and  often  afebrile  course.  Invagination  of  the  bowel  also 
gives  rise  to  a  palpable  tumor  and  to  constipation,  although  the  latter 
is  usually  preceded  by  thin  bloody  and  mucous  stools.  Fecal  impac- 
tion— coprostasis — is  unattended  with  inflammatory  manifestations 


264  DIGESTIVE  ORGANS 

(pain,  fever).  Tuberculosis  of  the  vertebral  column  or  of  the  pelvic 
bones  is  at  times  atteiuled  with  acciiimikition  of  pus  in  the  right 
iliac  fossa,  but  each  is  usually  associated  with  alterations  in  the 
vertebral  column  or  the  pelvic  bones  respectively.  Psoitis  is  unat- 
tended with  disturbance  in  intestinal  activity.  Carcinoma  and 
tuberculosis  of  the  mesenteric  glands  give  rise  to  the  formation  of 
multinodular  tumors.  At  times  it  is  impossible  to  ditJ'erentiate 
appendicitis  from  salpingitis.  Confusion  with  biliary  or  renal  colic 
can  be  avoided  if  jaundice  or  alterations  in  the  urine  be  present. 
Wandering  kidney  constitutes  a  smooth,  bean-shaped,  usually 
movable  tumor,  without  tenderness  on  pressure. 

Prognosis. — Tiie  prognosis  of  the  inflammatory  disorders 
under  consideration  is  not  unfavorable.  It  is  the  more  favorable 
the  more  certain  the  diagnosis,  and  the  more  clearly  the  clinician 
constantly  has  in  mind  the  therapeutic  measures  to  be  employed. 

Treatment. — Appendicitis  and  perityphlitis  should  be  treated, 
like  acute  peritonitis,  with  rest  in  the  recumbent  posture,  a  liquid 
diet  (milk,  beef-broth  with  egg,  coffee  with  milk,  tea  with  milk, 
dilute  wine),  and  opium : 

R  Powdered  opium,  0.03  (  h  grain) ; 

Sugar,  0.3    (4 J  grains).— M. 
Make  10  such  powders. 
Dose :  1  powder  every  two  hours. 

An  ice-bag  that  is  not  too  heavy  should  be  applied  over  the 
right  iliac  fossa.  When  the  acute  inflammatory  manifestations 
have  subsided  and  the  exudate  has  been  well  circumscribed,  the 
ice-bag  should  be  replaced  by  a  hot  cataplasm,  which  will  better 
favor  the  absorption  of  the  pus.  Severe  pain  will  frequently  be 
relieved  speedily  by  the  application  of  from  6  to  10  leeches. 
Treatment  with  opium  should  be  persisted  in  until  all  pain  in  the 
right  iliac  fossa  has  disappeared,  even  if  many  weeks  should  be 
required.  Some  persons,  however,  complain  of  nausea  and  in- 
creased pain  after  the  administration  of  opium.  Under  such 
circumstances  the  opium  should  be  replaced  by  subcutaneous  injec- 
tions of  morphin : 

R  ]\Iorphin  hydrochlorate,  0.3  (4J  grains) ; 

Glycerin, 

Distilled  water,  each,  5.0  (75  minims). — M. 

Dose:  0.5  (8  minims)  subcutaneously  twice  daily. 

Painless  residua  of  exudate  may  be  made  to  disappear  by  means 
of  daily  saline  baths  (5000  grams  of  salt  to  a  full  bath  at  a  tem- 
perature of  28°  R. — 95°  F.),  and  by  covering  the  skin  in  the 
right  iliac  fossa  Mith  a  flannel  cloth  smeared  with  mercurial  oint- 
ment or  with  potassium-iodid  ointment,  ctv  with  an  ointment  of 
iodoform  or  of  ichthyol.  ^lassage  may  also  be  practised  cau- 
tiouslv.  Especial  consideration  should  be  given  to  the  question 
as   to  whether,  and   how   often,  existing    constipation    should   be 


INFLAMMATION  OF  CECUM  AND  VERMIFORM  APPENDIX    265 

relieved.  In  the  presence  of  acnte  inflammatory  manifestations 
the  constipation  should  be  permitted  to  continue,  but  also  subse- 
quently it  will  be  sufficient  if  the  bowels  are  moved  once  every 
eight  days.  This  end  can  be  best  attained  by  means  of  a  glycerin- 
enema  (2.0 — 30  minims — glycerin  to  the  enema),  whose  action 
remains  rather  local.  To  avoid  recurrences  of  the  disease  certain 
dietetic  regulations  must  be  observed  (avoidance  of  an  excess  of 
vegetable  food,  daily  exercise  in  the  open  air,  care  to  secure  a 
daily  evacuation  of  the  bowels,  and  the  like).  At  times  appen- 
dicitis and  paratyphlitis  will  require  surgical  intervention,  and 
this  indication  may  arise  either  when  an  abscess  has  formed  in 
the  peritoneal  cavity,  or  if  rupture  of  pus  into  the  abdominal 
cavity  has  taken  place,  or,  finally,  in  cases  of  recu7Tence  of  the 
disease.  The  contention  of  some  surgeons  that  appendicitis  and 
perityphlitis  are  always  surgical  diseases  is  an  error,  as  most  cases 
pursue  a  favorable  course  with  internal  treatment.^ 

Incision  of  an  encapsulated  abscess  in  the  peritoneal  cavity  becomes  neces- 
sary in  order  to  avoid  rupture  of  the  pus,  although  it  is  often  difficult  to 
elicit  deep  fluctuation  with  certainty  through  the  tense  abdominal  wall. 
Although  exploratory  puncture  is  considered  by  some  physicians  as  wholly 
free  from  danger,  we  can  by  no  means  coincide  with  this  view,  and  fear  not 
without  reason  the  possibility  of  accidental  puncture  of  the  intestine,  and 
fecal  and  putrid  infection  of  the  inflammatory  products.  The  abdominal 
cavity  has  also  been  opened  after  rupture  of  the  pus  into  the  peritoneal  cavity, 
and  extensive  perforative  peritonitis,  the  fecal  and  purulent  masses  removed 
by  sponging  (toilet  of  the  peritoneum),  and  when  possible  also  the  appen- 
dix excised.  Repeatedly  recurring  perityphlitis  has  been  treated  by  resec- 
tion or  extirpation  of  the  vermiform  appendix.  Most  surgeons  select  for  the 
performance  of  the  operation  a  period  when  the  inflammatory  exacerbation 
has  come  to  an  end,  while  others  operate  at  the  time  of  the  attack.  In 
general,  the  first  method  mentioned  is  to  be  preferred,  and  the  latter  should 
be  selected  only  when  the  attack  itself  demands  surgical  intervention. 

Stercoral  typhlitis  requires  the  administration  of  purgatives. 
Intestinal  infusions  of  cold  water  by  means  of  Hegar's  funnel- 
apparatus  may  be  recommended,  because  their  action  is  rather 
restricted  to  the  large  intestine.  It  may  happen  that  the  first 
infusions  will  be  unattended  with  the  evacuation  of  any  fecal 
matter,  so  that  the  water  returns  from  the  bowel  almost  unchanged. 
Under  such  conditions  it  is  advisable  to  repeat  the  infusion  every 
three  hours,  in  order  to  soften  the  excessively  inspissated  fecal 
matters,  and  to  facilitate  their  progress  in  the  intestine.  Even 
if  copious  evacuation  of  the  bowels  have  taken  place,  the  infusion 
should  be  repeated  upon  the  following  days  in  order  to  empty 

^  With  these  views  the  consensus  of  clinical  opinion  is  scarcely  in  accord. 
The  results  from  the  medicinal  treatment  of  appendicitis  are  at  least  uncertain. 
The  administration  of  an  opiate  is  likely  to  mask  the  symptoms  and  induce  a 
false  sense  of  security.  Should  the  bowels  remain  constipated  despite  the  admin- 
istration of  a  laxative,  and  especially  if  vomiting  be  present,  operation  should  be 
resorted  to. — A.  A.  E. 


266  DIGESTIVE  ORGANS 

the  bowel  as  thoroughly  as  possil)le.  In  addition,  a  hot  cataplasm 
should  he  applied  over  the  right  iliac  fossa  for  the  contn^l  of  the 
inflammatory  manifestations.  The  patient  must  thereafter  secure 
regular  evacuation  of  the  bowels. 

Parafi/phlitis  is  rather  a  surgical  disease.  An  effort  should 
be  made  by  means  of  hot  cataplasms  to  induce  aljsorption  of  the 
inflammatory  products,  but  should  fluctuation  appear  incision  of 
the  accumulation  of  pus  should  be  undertaken. 

ROUND  ULCER  OF  THE  DUODENUM. 

Round  ulcer  of  the  duodenum  is  a  rare  disorder  whose  devel- 
opment, manifestations,  and  treatment  coincide  with  those  of 
round  ulcer  of  the  stomach.  The  condition  is  attended  with  a 
sharply  circumscribed  loss  of  tissue  in  the  mucous  membrane  of 
the  duodenum  of  circular  outline,  and  resulting  from  the  digestive 
activity  of  gastric  juice  that  has  entered  the  duodenum  "svheneyer 
local  stagnation  has  taken  place  in  the  blood-vessels  of  the 
mucous  membrane.  The  lesion  may  thus  be  designated  a  diges- 
tive or  a  peptic  ulcer.  Duodenal  ulcers  are  almost  unexceptioually 
found  above  the  point  of  entrance  of  the  choledoch  duct  into  the 
duodenum,  most  frequently  in  the  upper  horizontal  segment,  for 
below  the  entrance  of  the  choledoch  duct  the  gastric  juice  becomes 
inactive,  because  the  bile  causes  precipitation  of  the  pepsin,  and 
the  alkaline  intestinal  and  pancreatic  juices  neutralize  the  hydro- 
chloric acid  of  the  gastric  juice.  Nothing  definite  is  known  with 
regard  to  the  causes  of  round  ulcer  of  the  duodenum.  In  numer- 
ous instances  the  condition  has  been  observed  to  develop  after 
burns  of  the  ski)i.  Experience  has  shown  that,  in  contrast  with 
round  ulcer  of  the  stomach,  duodenal  ulceration  occurs  more  com- 
monly in  men  than  in  women.  Pain  in  the  right  upper  quadrant 
of  the  abdomen  is  quite  a  constant  symptom,  and  in  the  differen- 
tiation from  round  ulcer  of  the  stomach  emphasis  has  been  placed 
upon  the  fact  that  this  pain  does  not  succeed  immediately  upon 
the  ingestion  of  food,  but  it  appears  only  after  tlie  lapse  of  from 
two  to  four  hours,  when  the  gastric  contents  enter  the  duodenum. 
Often  duodenal  hemorrhage  takes  place.  This  most  frequently 
gives  rise  to  bloody  stools,  and  much  less  commonly  also  to  hemate- 
mesis.  Perforation  of  the  ulcer  is  a  serious  danger,  and  this  may 
take  place  either  free  into  the  abdominal  cavity,  and  then  give 
rise  to  rapidly  fatal  perforative  peritonitis,  or  into  a  previously 
encapsulated  cavity.  Two  of  my  patients  died  at  an  advanced 
age  o(  carcinoma  of  the  dxiodennm,  which  developed  at  the  margins 
of  a  round  ulcer  of  the  duodenum.  In  one  of  the  cases  metastatic 
growths  developed  in  the  spinal  cord,  with  pressure-paralysis,  and 
in  the  other  secondary  carcinoma  of  the  liver  occurred.  Should 
cicatrization    of  a    duodenal  ulcer  take  place    cicatricial   stenosis 


CARCINOMA    OF  THE  INTESTINE  267. 

of  the  duodenum,  and  above  the  constriction  dilatation  of  the  duo- 
denum, of  the  stomach,  and  even  of  the  esophagus,  may  result. 

The  prognosis  is  grave  under  all  conditions.  At  times  ulcer 
of  the  duodenum  develops  insidiously,  and  causes  death  within  a 
short  time  from  uncontrollable  hemorrhage  or  from  perforative 
peritonitis. 

The  treatment  is  the  same  as  that  for  round  ulcer  of  the 
stomach  (pp.  220-222). 

CARCINOMA  OF  THE  INTESTINE. 

Btiology  and  Anatomic  Alterations. — Nothing  definite 
is  known  with  regard  to  the  causes  of  carcinoma  of  the  intestine, 
and  the  knowledge  must  suffice  that  carcinoma  of  this  organ,  like 
that  of  other  organs,  is  a  disease  of  advanced  years.  Only  rarely 
does  the  disorder  appear  before  the  fortieth  year  of  life.  That  in 
a  small  number  of  cases  it  may  develop  from  an  ulcer  of  the  intes- 
tine has  already  been  pointed  out  in  the  preceding  section.  Car- 
cinoma of  the  intestine  occurs  more  commonly  in  men  than  in 
women. 

Almost  always  the  netv-growth  is  primary.  Secondary  carci- 
noma of  the  intestine  is  rare.  Most  commonly  the  new-growth  is 
seated  in  the  large  intestine,  and  particularly  in  the  rectum.  The 
flexures  of  the  bowel  are  attacked  with  especial  preference,  perhaps 
because  in  these  situations  the  mucous  membrane  is  subjected  to 
particularly  active  mechanical  irritation  by  the  advancing  column 
of  fecal  matter.  Accordingly,  the  sigmoid  flexure,  the  hepatic 
flexure,  and  the  splenic  flexure  of  the  colon  and  the  cecum  are  the 
principal  seats  of  carcinoma  of  the  bowel.  The  most  common  form 
of  carcinoma  of  the  intestine  is  the  annular  variety,  the  entire 
circumference  of  the  bowel  being  involved  in  the  new-growth. 
Accordingly  as  the  carcinomatous  tissue  is  dense  and  deficient 
in  fluid,  of  medullary  consistency,  or  traversed  by  cavities  with 
gelatinous  contents,  a  distinction  is  made,  as  with  carcinoma  in 
other  organs,  between  scirrhous,  medullary,  and  alveolar  carcinoma. 
Histologically  the  new-growth  is  a  cylindrical-cell  carcinoma,  as 
its  cellular  elements  result  from  abnormal  proliferation  of  the 
epithelial  cells  of  the  glands  of  the  intestinal  mucous  membrane. 
Disintegration  of  carcinomatous  tissue  gives  rise  to  carcinomatous 
ulcers.  Under  such  conditions  the  destruction  of  tissue  may  be 
so  extensive  that  possibly  remains  of  carcinomatous  tissue  are 
found  only  at  the  margins  of  the  ulcer.  This  process  is  attended 
with  two  dangers,  namely,  hemorihiage  from  and  perforation  of  the 
intestine.  Should  the  ulcers  undergo  cicatrization,  stenosis  of  the 
bowel  results  at  times  in  consequence  of  contraction  of  the  cica- 
tricial tissue.  Dilatation  of  the  intestine  occurs  not  rarely  above 
the  position  of  the  new-growth,  because  the  lumen  of  the  bowel 


268  DIGESTIVE  ORGANS 

is  diniinislied  by  tlie  carcinoma  or  the  cicatrix.  If,  naturally,  the 
carcinDmatous  tissue  has  undergone  extensive  disintegration,  the 
lumen  of  the  bowel  may  be  converted  into  a  large  cavity  at 
the  site  of  the  ne\v-gr<)\\th. 

Symptoms  and  Diagnosis. — The  diagnosis  of  carcinoma 
of  the  intestine  can  scarcely  be  made  with  certainty  unless  it  has 
been  possible  to  deliionstrate  the  presence  of  a  nodular  tumor  of  the 
bowel,  which  has  undergone  gradually  progressive  increase  in  size 
in  a  person  of  advanced  years,  and  is  attended  with  progressive 
asthenia  and  anemia.  The  tumor  may  be  felt  either  through  the 
abdominal  wall  or  after  introduction  of  the  anointed  finger  into  the 
vagina  or  tiie  rectum.  Carcinoma  of  the  rectum  may  at  times  be 
accessible  also  to  ocular  inspection  after  the  introduction  of  a  rectal 
speculum.  In  addition  there  are  also  changes  in  intestinal  activity. 
The  patient  usually  suifers  from  constipation  as  long  as  the  new- 
growth  diminishes  the  lumen  of  the  bowel,  and  as  a  result  the 
abdomen  may  he  tensely  distended  in  consequence  of  stagnation  of 
fecal  matter  and  gas.  At  times  the  feces  present  a  pecidiar  shape, 
appearing  as  small,  abbreviated  columns,  like  the  fecal  matter  of 
the  sheep  or  the  goat.  It  is  true  that  the  feces  acquire  a  similar 
appearance  also  in  cases  of  inanition  and  in  connection  Avith 
obstinate  constipation,  if  the  latter  be  due  to  spasmodic  contrac- 
tion-of  the  musculature  of  the  intestine.  Should  disintegration 
of  the  carcinomatous  tissue  take  place  subsequently,  diarrhea  fre- 
quently occurs.  The  thin  intestinal  evacuations  not  rarely  are 
noteworthy  for  their  putrid  and  fetid  odor,  and  they  contain  blood 
and  pus.  The  discovery  in  them  of  fragments  of  carcinomatous 
tissue  that  can  be  definitely  recognized  as  such  on  microscopic 
examination  is  an  exceedingly  uncommon  event.  The  patient 
often  suffers  from  severe  pain  at  the  site  of  disease,  and  this  fre- 
quently is  especially  severe  at  night ;  the  tumor  is  further  exceed- 
inglv  tender  to  touch.  The  urine  is  generally  passed  in  diminished 
amount,  and  it  contains  an  increased  amount  of  indican.  The 
inguinal  lymphatic  glands  arc  frequently  enlarged  and  indurated. 
Although  the  appetite  is  impaired,  thirst  is  generally  increased. 
The  bodily  temperature  is  frequently  elevated  if  the  carcinomatous 
tissue  is  in  process  of  disintegration  and  gangrene,  and  under  such 
conditions  septic  symptoms — chills — are  also  observed. 

The  diagnosis  of  nro])hisrn  of  the  intestine  must  not  be  consid- 
ered as  by  any  means  easy.  It  is  important,  in  the  first  place, 
to  localize  the  new-growth  correctly,  in  order  not  to  confound  it 
with  neoplasms  of  the  stomach,  the  liver,  the  kidneys,  the  omen- 
tum, the  mesentery,  and  the  abdominal  lymphatic  glands,  and  with 
enca]>sulated  peritoneal  exudates — perityphlitis.  In  the  differential 
diagnosis  the  situation  and  the  mobility  of  the  tumor,  and  the 
existence  of  functional  disturbances,  should  particularly  be  given 
consideration.      It  may  be  of  diagnostic  importance  to  fill  the 


CARCINOMA    OF  THE  INTESTINE  269 

intestine  alternately  with  air  and  water  through  the  rectum,  in 
order  to  determine  the  situation  of  the  tumor  and  the  variations 
in  the  percussion-note  over  it.  If  a  neoplasm  has  been  recognized 
as  arising  from  the  intestine,  it  next  becomes  necessary  to  decide 
whetlier  it  be  carcinomatous  or  not.  Insidiousness  of  development, 
advanced  age,  and  progressive  marasmus  are  suggestive  of  car- 
cinoma. Especial  consideration  in  the  differential  diagnosis  should 
be  given  to  fecal  tumors,  which  likewise  give  rise  to  nodular 
intestinal  swellings.  These,  however,  are  unattended  with  pro- 
gressive marasmus,  and  they  not  rarely  permit  the  production 
of  depressions  with  the  finger,  and,  above  all,  they  disappear  when 
purgatives  are  employed  for  a  sufficiently  long  period.  It  should, 
however,  be  made  a  rule  in  the  diagnosis  of  intestinal  tumors  to 
pursue  a  course  of  purgative  treatment,  even  when  the  conditions 
appear  clear,  as  the  danger  of  error  in  diagnosis  is  considerable. 

The  duration  of  carcinoma  of  the  irdestine  but  rarely  extends 
over  more  than  a  year,  and  many  patients  die  in  consequence  of 
progressive  asthenia,  after  marantic  edema  or  venous  thrombi  have 
developed  in  the  lower  extremities,  or  amid  septic  manifestations. 
At  times,  in  consequence  of  auto-infection,  a  comatose  state  de- 
velops rather  suddenly,  in  which  tiie  patient  dies — carcinomatous 
auto-intoxication  or  coma.  At  times,  however,  death  results  from 
complications,  among  which  hemorrhage  from  the  boioel,  obstruction 
of  the  bowel,  and  rupture  of  the  bowel  particularly  may  be  men- 
tioned. As  may  be  readily  understood,  hemorrhage  from  the  bowel 
may  accelerate  the  loss  of  strength,  especially  if  it  be  repeated 
frequently,  and,  if  it  be  uncontrollable,  death  will  result  from 
hemorrhage.  At  times  the  symptoms  of  obstruction  of  the 
bowel  or  ileus  appear  suddenly,  with  insurmountable  constipation, 
absence  of  flatus,  and  fecal  vomiting.  This  danger  is  especially 
to  be  feared  when  the  patient  is  indifferent  with  regard  to  regu- 
larity in  the  movement  of  the  bowels  or  incautiously  indulges  in 
indigestible  articles  of  food^leguminous  plants  or  fruit  with 
kernels.  Rupture  of  the  bowel  may  take  place  in  various  direc- 
tions, as,  for  instance,  into  the  peritoneal  cavity,  when  rapidly 
fatal  peritonitis  usually  follows ;  into  adjacent  loops  of  intestine, 
when  a  bimucous  intestinal  fistula  forms;  in  cases  of  carcinoma 
of  the  cecum  into  retrocecal  connective  tissue,  with  gangrene 
thereof;  into  the  stomach,  the  urinary  passages,  the  vagina;  or 
externally,  through  the  skin,  with  the  formation  of  a  fecal  fistula 
or  preternatural  anus.  At  times  complications  result  from  the 
situation  of  the  new-growth  in  the  intestine.  Carcinoma  of'  the 
duodenum  not  rarely  develops  at  the  papilla  of  Vater,  and  by 
pressure  upon  the  choledoch  duct,  which  enters  at  this  point,  gives 
rise  to  chronic  jaundice.  If  the  tumor  be  situated,  however,  in 
the  upper  portion  of  the  duodenimi,  it  will  give  rise  to  dilatation 
of  the  stomach. 


270  DIGESTIVE  ORGANS 

Frequently  carcinoma  of  the  rectum  is  recognized  either  not  at 
all  or  so  late  that  the  proper  time  for  operative  intervention  is  per- 
mitted to  escape.  Pain  in  the  sacnnn,  often  radiating  to  the 
pelvis  and  the  thighs,  inuc(j[)urulent  and  l)loody  diarrhea,  and  the 
development  of  hemorrhoids  in  elderly  persons  should  ahvavs 
demand  digital  examination  of  the  rectum.  Often  paralysis  of 
the  sphincter  ani  muscle  develops,  so  tiiat  putrid  fecal  matter  con- 
stantly escapes  from  the  anus,  and  the  patients  must  protect  them- 
selves against  the  incontinence  as  best  they  can  by  means  of  linen 
cloths  or  paper.  Carcinoma  of  the  rectum  sometimes  pursues  a 
most  protracted  course.  One  of  my  patients  died  only  after  the 
lapse  of  five  years. 

It  should  further  be  mentioned  that  carcinoma  of  the  intestine 
may  be  latent,  not  being  recognized  at  all  during  life,  or  under 
favorable  conditions  only  being  suspected  to  the  point  of  proba- 
bility from  the  presence  of  certain  symptoms.  Thus,  in  elderly 
persons  intestinal  hemorrhage  or  ileus  is  frequently  associated  \vith 
latent  carcinoma  of  the  bowel,  as  is  also  fecal  fistula.  At  times 
carcinoma  of  the  bowel  is  concealed  behind  a  carcinomatous  peri- 
tonitis. 

Prognosis. — The  prognosis  of  intestinal  carcinoma  is  unfavor- 
able, for  even  if  an  operation  will  prolong  the  life  of  the  patient, 
recurrence  or  metastasis  occurs  as  a  rule,  and  life  cannot  be  pro- 
longed for  any  considerable  length  of  time. 

Treatment. — Carcinoma  of  the  intestine  can  be  cured  only  by 
operative  measures  through  resection  of  the  portion  of  intestine 
involved  in  the  malignant  disease.  Naturally,  certain  limitations 
surround  the  employment  of  the  knife.  The  area  involved  should 
especially  not  be  too  extensive  in  length,  nor  should  metastases  in 
other  viscera  be  present.  Fiu'ther,  extensive  adhesions  may  render 
operation  not  only  exceedingly  difficult,  but  even  impossible.  If 
resection  of  the  carcinomatous  bowel  be  impossible,  the  establish- 
ment of  a  preternatural  anuf<  above  tlie  new-growth,  or  entero- 
aiiadomosis,  is  yet  available,  but  this  will  be  indicated  only  when 
symptoms  of  stricture  of  the  bowel  appear.  In  cases  of  inoper- 
able carcinoma  of  the  rectum  curetting  and  destruction  of  the  new- 
growth  with  the  galvanocautery  have  been  undertaken.  Internal 
treatment  will  be  confined  to  lessening  the  sufferings  of  the  patient 
symptomatically  and  maintaining  his  strength  as  fully  as  possible 
by  means  of  suitable  diet  (milk,  meat-broth,  eggs,  wine). 

Among  the  remaining  tumors  of  the  intestine  sarcomata  and  polypi  are 
yet  of  clinical  interest.  Sarcomata  of  tlie  intestine  give  rise  to  the  same  symp- 
toms as  carcinomata,  so  that  they  are  indistinguishable  from  the  latter 
during  life.  They  are  much  less  common  than  carcinomata,  and  usually 
develop  as  primary  neoplasms.  Polypi  of  the  intestine  develop  not  rarely  in 
children,  and  are  often  situated  in  the  rectum.  The  patients  suffer  fre- 
quently from  chronic  nuicous  or  mucous  and  bloody  diarrhea.  Solid  masses 
of  fecal  matter  are  sometimes  conspicuous  from  the  presence  of  a  depression 


INVAGINATION  OB  INTUSSUSCEPTION  OF  THE  BOWEL  271 

resulting  from  the  pressure  exerted  by  a  polyp.  Deep-seated  polypi  may  at 
times  protrude  from  the  anus.  Sometimes  polypi  are  detached  by  the 
pressure  of  the  column  of  fecal  matter  and  are  found  in  the  stools.  If  the 
anointed  finger  be  introduced  into  the  rectum,  the  soft,  smooth  tumors  can 
often  be  felt.  Removal  can  be  effected  only  by  operative  measures.  Polypi 
at  a  higher  level  in  the  bowel  at  times  give  rise  to  obstruction,  or  intussuscep- 
tion. 

INVAGINATION  OR  INTUSSUSCEPTION  OF  THE 

BOWEL. 

Anatomic  Alterations. — Invagination  of  the  bowel  results 
from  the  inversion  of  one  portion  of  the  bowel  into  an  adjacent 
portion,  like  the  finger  of  a  glove.  The  invaginated  portion  is 
known  as  the  intussusceptum,  while  the  external  ensheathing  por- 
tion of  bowel  is  designated  the  sheath  or  intussuseipiens.  A  dis- 
tinction is  made  between  the  inner  or  entering,  and  the  outer  or 
departing,  portion  of  intestine.  The  point  of  reflection  from  the 
sheath  to  the  intussusceptum  is  known  as  the  upper  angle  of  reflec- 
tion, while  the  point  of  reflection  between  the  outer  and  the  inner 
portion  of  intestine  of  the  intussusceptum  is  known  as  the  lower 
angle  of  reflection.  A  distinction  is  further  made  between  descend- 
ing and  ascending  invagination  of  the  bowel,  accordingly  as  an  upper 
portion  becomes  inverted  into  a  lower,  or  a  lower  into  an  upper. 
All  varieties  of  intestinal  invagination  do  not  have  clinical  signifi- 
cance, and  a  clear  distinction  must  be  made  between  -yite/  and 
agonal  intussusception.  The  latter  is  unattended  with  interest,  and 
occurs  with  especial  frequency  in  children  that  have  passed  through 
a  protracted  death-struggle  or  have  suffered  from  diarrhea. 

Agonal  invagination  of  the  bowel  may  be  recognized  from  the  fact  that  it 
is  frequently  multiple  and  situated  at  different  parts  of  the  bowel,  is  often 
ascending,  almost  always  involves  the  small  intestine,  is  free  from  all  inflam- 
matory alterations,  and  can  therefore  be  reduced  without  difliculty  by  trac- 
tion on  the  bowel. 

Vital  invagination  of  the  boivel  is  almost  unexceptionally  descend- 
ing and  single.  Naturally,  together  with  the  bowel  the  related 
mesentery  is  also  invaginated,  in  consequence  of  which  traction  is 
usually  exerted  upon  the  invaginated  intestine,  so  that  the  intus- 
susceptum presents  a  concavity  on  its  mesenteric  aspect  and  a 
fissure-like  constriction  at  its  lower  extremity.  It  can  be  readily 
understood  that  invagination  of  the  intestine  is  attended  with  the 
danger  of  stricture  or  obstruction  of  the  bowel.  Another  danger 
arises  from  the  fact  that  nutritive  disturbances  may  occur  in  the 
intussusceptum,  in  consequence  of  compression  of  the  mesenteric 
vessels — either  inflammatory  adhesions  and,  distortions  or  gangrene 
of  the  bowel.  Most  commonly  the  ileum  with  the  ileocecal  valve 
in  advance  is  inverted  into  the  colon — ileocecal  invagination. 
Under  such  conditions  the  invagination  of  the  bowel  has  a  ten- 


079 


DIGESTIVE  ORGANS 


dency  to  increase  gradually  in  size  in  consequence  of  the  pressure 
exerted  by  the  column  of  fecal  matter,  and  in  this  way  the  flex- 
ures of  the  colon  may  be  obliterated  and  be  represented  by  a  band 
passing  transversely  from  one  to  the  other  iliac  fossa.  At  times 
the  invaginated  portion  of  intestine  may  protrude  a  greater  or 
lesser  distance  from  the  anus. 

In  order  to  indicate  by  name  the  situation  of  an  invagination  of  the 
bowel  the  following  nomenclature  has  been  adopted:  Jejunal  or  iliac  invagi- 
nation indicates  that  a  portion  of  the  jejunum  or  the  ileum  has  become 
invaginated  into  another  portion  of  bowel  of  the  same  name.  Jejuno-iliac 
invagination  indicates  inversion  of  the  jejunum  into  the  ileum.  An  ileo- 
colic invagination  is  distinguished  from  an  ileocecal  invagination  by  the 
fact  that  in  the  former  the  ileum  has  found  its  way  through  the  ileocecal 
valve  into  the  colon,  while  in  the  ileocecal  invagination  the  valve  with  the 
ileum  is  inverted. 

Individuals  dead  of  invagination  of  the  bowel  usually  exhibit 
evidences  of  peritonitis,  or  of  rupture  of  the  bowel,  or  of  septico- 
pyemia. 

Ktiology. — Children  are  most  commonly  attacked  i)y  invagi- 
nation of  the  bowel,  and  boya  more  commonly  than  girls.  The 
disorder  develops  with  especial  frequency  bchceen  the  finrd  and  the 
twelfth  month  of  life.  Both  constipation  and  diarrhea  are  named 
as  causes.  At  times  intestinal  polypi  induce  invagination  by 
exerting  traction  directly  on  the  intestinal  wall.  Invagination  has 
also  been  observed  in  connection  with  stricture  of  the  bowel,  as, 
for  instance,  from  carcinoma.  Injuries  of  the  abdominal  walls,  as 
by  a  fall  or  a  blow,  have  also  been  mentioned  as  causative  factors. 

The  mechanical  occurrence  of  invagination  of  the  bovel  has  been  repeat- 
edly discussed  and  investigated  experimentally.  The  conditions  are  clear- 
est in  cases  in  which  a  tumor,  by  its  weight,  has  gradually  pulled  the 
intestinal  wall  inward  and  downward.  Under  other  conditions  it  seems 
most  probable  and  most  natural  to  explain  the  development  of  invagina- 
tion of  the  bowel  by  conceiving  that  a  portion  of  intestine  engaged  in  active 
movement  slips  into  another  portion  of  bowel  situated  beyond  it,  and  at 
rest.  The  slipping  of  a  lower  segment  of  bowel  over  an  upper  is  an  unnat- 
ural process.  The  invagination  of  a  loop  of  intestine  will  occur  the  more 
readily  if  the  adjacent  portion  of  bowel  is  paralyzed  or  constricted  by  mus- 
cular spasm,  and  accordingly  a  distinction  has  been  made  between  parali/tie 
and  sj)astic  invagination  of  the  bowel.  The  first  variety  is  believed  to  be  the 
more  common. 

Symptoms  and  Diagnosis. — With  the  onset  of  invagina- 
tion of  the  bowel  the  patients  are  as  a  rule  seized  with  abdominal 
pain  so  severe  as  to  compel  them  to  cry  out.  The  pain  occurs 
paroxysmally,  and  is  colicky  for  the  succeeding  twenty-four  or 
thirty-six  hours.  In  most  patients  there  is  also  repeated  vomiting. 
Soon  there  apj^ear  in  addition  alterations  in  the  stools,  whi<'h 
may  be  thin  and  contain  mucus  and  blood.  Often  the  anus  is 
open  in  consequence  of  paralysis  of  the  sj^hincter,  and  mucus  and 
bloody  fluid    constantly  trickle  out.      The  anal  orifice   appears 


INVAGINATION  OR  INTUSSUSCEPTION  OF  THE  BOWEL  273 

retracted,  and  the  skin  in  its  vicinity  is  unusually  smooth.  Soon, 
however,  the  diarrhea  ceases,  and  is  replaced  by  obstinate  con- 
stipation. 

The  diagnosis  of  invagination  of  the  bowel  becomes  the  more 
certain  if  examination  of  the  abdomen  discloses  the  presence 
of  a  tumor,  which  is  most  frequently  situated  in  the  umbilical 
region  or  the  right  iliac  fossa.  This  tumor  is  of  oval  shape, 
almost  like  that  of  a  sausage,  with  a  smooth  surface,  and  at  first 
of  inconsiderable  tenderness  on  pressure.  It  is,  further,  dis- 
tinctive that  not  rarely  it  gradually  changes  its  position  and 
increases  in  size,  in  accordance  with  the  increase  in  the  invagina- 
tion. At  times  it  extends  transversely  from  one  iliac  fossa  to  the 
other.  In  consequence  of  gaseous  distention  of  the  intestines  and 
great  tension  of  the  abdominal  walls,  it  may  be  exceedingly  diffi- 
cult after  the  lapse  of  a  few  days  to  appreciate  the  presence  of  a 
tumor  through  the  abdominal  walls,  even  if  all  the  aid  of  the  usual 
devices  is  invoked — examination  with  warm  hands,  the  knee- 
elbow  position,  conversation  with  the  patient  during  the  examina- 
tion, examination  in  a  warm  bath,  chloroform-narcosis.  Exami- 
nation of  the  rectum  with  the  anointed  finger  should  never  be 
omitted,  as  it  is  possible  at  times  to  feel  the  invaginated  portion 
of  bowel  in  the  rectum  itself  or  in  the  vicinity.  Little  diagnostic 
aid  will,  as  a  rule,  be  yielded  by  the  introduction  of  a  sound  into 
the  rectum  or  by  an  infusion  into  the  bowel. 

The  influence  exerted  by  the  intestinal  alterations  upon  the 
general  condition  is  noteworthy.  Symptoms  of  shock  appear,  as 
manifested  by  a  cold  skin,  shrunken  features,  an  anxious  expres- 
sion, and  a  small,  accelerated  pulse.  Under  especially  favorable 
conditions  invagination  of  the  bowel  may  undergo  spontaneous 
reduction,  or  it  may  be  reduced  by  artificial  aid,  and  all  of  the 
morbid  manifestations  disappear.  Much  more  commonly  serious 
dangers  arise,  among  which  symptoms  of  ileus  occupy  first  place. 
This  mav  be  recognized  from  the  presence  of  insurmountable 
constipation,  the  failure  of  gas  to  escape  from  the  anus,  and 
the  occurrence  of  vomiting,  with  evacuation  at  first  of  the  con- 
tents of  the  stomach,  then  of  bilious  intestinal  contents,  and 
finally  of  material  of  fecal  odor  and  appearance — so-called  fecal 
vomiting,  miserere.  Although  this  condition  alone  is  indicative 
of  serious  menace  to  life,  this  becomes  in  marked  degree  greater 
from  the  development  within  a  short  time  oi  jperitoniti.'i,  originat- 
ing at  the  point  of  intussusception,  and  soon  extending  to  the 
entire  peritoneum.  Progressive  distention  of  the  abdomen,  espe- 
cially severe  pain  on  palpation  of  the  abdomen,  here  and  there 
developing  dulness  on  percussion  of  the  abdominal  wall,  in  corre- 
spondence with  disseminated  accumulations  of  exudate  between 
adherent  loops  of  bowel,  usually  permit  ready  recognition  of  the 
process.     At  times  rupture  of  the  bowel  takes  place  from  lacera- 

18 


274  DIGESTIVE  ORGANS 

tion  of  the  gangrenous  intestine.  An  already  existing  inflamma- 
tion of  the  jx'ritonciim  l)ecomes  in  consequence  transformed  into 
a  fecal  and  putrid  peritonitis. 

At  times  natural  recovery  takes  place  from  invagination  of  the 
bowel  by  gangrenous  exfoliation  of  the  invaginated  portion  of  intes- 
tine, and  evacuation  with  the  stools,  in  consequence  of  which  the 
previously  oeeluded  intestine  becomes  again  patulous.  INIost  fre- 
quently spontaneous  separation  of  the  gangrenous  bowel  takes  place 
between  the  eleventh  and  the  twenty-tirst  day.  It  is  usually  re- 
vealed by  the  occurrence  of  stools  of  extremely  offensive  odor  and 
often  of  bloody  character,  in  which  black,  necrotic  shreds  and  at 
times  also  portions  of  bowel  of  considerable  length  are  encountered. 
Further,  the  separation  of  the  gangrenous  portion  of  the  bowel 
may  be  attended  with  serious  dangers,  among  which  uncontrollable 
hciiiorrhaye  from  and  perforation  of  the  bowel  may  be  mentioned.  At 
times  also  i^ejjticojn/emia  is  superadded  in  consequence  of  absorp- 
tion of  gangrenous  material,  and  as  a  result  of  which  death  takes 
place.  Attention  should  be  called  here  to  an  important  sequel  of 
invagination  of  the  bowel.  Should,  subsequently,  considerable 
contraction  of  the  cicatricial  tissue  take  place  at  the  point  of  sepa- 
ration, stricture  of  the  bowel  and  even  occlusion  of  the  bowel  may 
result,  and  in  consequence  of  which  death  may  take  place. 

The  course  and  the  duration  of  invagination  of  the  bowel  may 
be  peracute,  acute,  subacute,  or  chronic,  accordingly  as  a  few  hours, 
days,  weeks,  or  months,  or  even  years  transpire.  In  the  first 
event  death  results  amid  symptoms  of  shock.  It  is  noteworthy, 
further,  that  intestinal  invagination  exhibits  a  great  tendency  to 
recurrence.  It  is  often  possible  to  relieve  the  invagination,  but  it 
recurs  within  a  few  hours.  The  cases  are  rare  in  which  an  invag- 
inated portion  of  bowel  has  protruded  persistently  from  the  rec- 
tum, and  has  required  operative  intervention  for  its  removal. 

Prognosis. — Invagination  of  tlie  bowel  always  demands  a 
serious  prognosis,  but  the  probabilities  of  a  favorable  issue  have 
become  materially  improved  of  late  since  it  has  been  learned  that 
some  of  the  dangers  can  be  averted  by  operation. 

Treatment. — It  is  an  almost  obvious  indication  that  jiersons 
with  invagination  of  the  bowel  should  remain  constantly  in  bed, 
and  partake  in  small  amount  of  exclusively  liquid  nourishment 
(milk,  milk  and  coffee,  meat-broth),  a  teaspoonful  or  tablespoonful 
at  intervals  of  half  an  hour.  Besides,  a  hot  cataplasm  should  be 
applied  to  the  abdomen,  and  opium  be  administered  internally  in 
order  to  relieve  the  ]iain,  and  to  keep  the  bowel  at  rest,  thereby 
avoiding  the  occurrence  of  inflammation  and  extension  of  the  in- 
flammatory process.  It  should,  however,  be  borne  in  mind  that 
children,  and  especially  infants,  are  exceedingly  susceptible  to  the 
action  of  opium,  so  that  even  small  doses  may  at  times  be  followed 
by  serious  symptoms  of  intoxication.     Instead  of  opium,  morphin 


STENOSIS  AND   OBSTRUCTION  OF  THE  BOWEL         275 

may  be  employed  subcutaneously.  Then  an  attempt  should  be 
made  to  reduce  the  invagination  by  mechanical  means.  For  this 
])urpose  intestinal  infusions  of  cold  water  are  to  be  preferred,  and 
tliese,  if  necessary,  may  be  repeated  thrice  or  four  times  during 
the  day.  In  order  that  the  water  introduced  may  reach  as  high  a 
point  in  the  bowel  as  possible,  the  patient  should  occupy  the  knee- 
elbow  posture  or  the  pelvis  should  be  elevated.  Rectal  injections 
in  chloroform -narcosis  may  also  be  practised.  At  times  the  invag- 
ination may  be  observed  to  correct  itself  with  a  distinctly  audible 
murmur.  The  employment  of  injections  of  air  or  of  carbon  dioxid 
is  less  convenient  and  in  my  opinion  less  efficient  than  that  of 
injections  of  water  into  the  bowel.  Injections  of  air  are  made 
most  simply  with  the  aid  of  a  rectal  tube^  connected  with  the  bulb 
of  a  Richardson  spray-apparatus.  In  cases  in  which  the  invagina- 
tion has  advanced  to  the  rectum  an  attempt  may  be  made  to 
eifect  reduction  by  means  of  a  long  but  not  too  rigid  rectal  bougie 
(sponge-bougie).  If  recurrences  of  the  invagination  take  place, 
it  may  become  necessary  to  permit  the  sound  to  remain  in  the 
rectum,  fastening  it  externally. 

Attempts  have  also  been  made  to  reduce  invagination  of  the  bowel  by 
means  of  abdominal  massage,  but  this  procedure  cannot  be  considered  as 
entirely  free  from  danger. 

If  all  efforts  have  been  unattended  with  success,  surgical  treat- 
ment becomes  necessary.  It  is  particularly  important  not  to  defer 
this  too  long,  for  if  necrotic  alterations  have  already  taken  place 
in  the  intestines,  or  if  extensive  peritonitis  has  developed,  the 
results  of  operation  may  also  be  doubtful.  The  operative  pro- 
cedure will  depend  upon  the  existing  conditions.  Opening  of  the 
abdomen  (celiotomy),  determination  of  the  situation  of  the  invagi- 
nation, and  reduction  by  traction  upon  the  bowel  will  first  have 
to  be  considered.  At  times  loops  of  bowel  have  been  fastened  by 
means  of  sutures  in  order  to  prevent  recurrence.  If,  however, 
the  invaginated  portions  of  bowel  have  already  become  so  adher- 
ent that  separation  is  not  possible,  only  two  procedures  remain 
feasible,  namely,  e'lthev  resection  of  the  invaginated  portion  of  bovel 
or  the  establishment  of  an  intestinal  fistida  above  the  point  of  in- 
vagination. In  the  latter  event  there  would  still  be  danger  that 
gangrene  might  develop  at  the  point  of  invagination,  with  its  seri- 
ous consequences. 

STENOSIS  AND  OBSTRUCTION  OF  THE  BOWEL 
(ENTEROSTENOSIS  AND  ILEUS), 

Ktiology. — The  causes  of  stenosis  or  of  obstruction  of  the 
bowel  may  be  congenital  or  acquired.  Congenital  obstruction  of  the 
bowel  is  rare,  and  occurs  when  the  anus  is  occluded  or  when  in 


276  DIGESTIVE  ORGANS 

the  upper  portion  of  the  bowel  deficient  development  and  closure 
in  certain  portions  of  the  intestine  have  taken  place.  Death  will 
occur  soon  after  birth,  unless  in  the  presence  of  congenital  atresia 
of  the  anus  the  lumen  of  the  intestinal  tube  can  be  rendered  patu- 
lous by  means  of  an  operation.  Acquired  stenosis  and  obstruction 
of  the  bowel  are  divided  into  intra-intestinal,  extra-intestinal,  and 
parietal  varieties,  in  a(;cordance  with  the  situation  of  the  causative 
conditions.  Among  intra-intestinal  caasatice  conditions  fecalaccuniu- 
lation — coprostasis — occupies  first  place.  Such  a  condition  may  be 
induced  by  the  presence  o^ foreign  bodies  in  the  intestine.  At  times 
the  foreign  bodies  may  have  been  swallowed  (bone,  tendon,  fibrous 
remains  of  asparagus,  fruit-kernels,  masses  of  shellac,  etc.)  ;  at 
other  times  they  may  have  been  introduced  into  the  rectum  through 
the  anus,  as,  for  instance,  bottles ;  and  at  still  other  times  they 
may  consist  of  substances  from  viscera  whose  excretory  ducts  dis- 
charge into  the  intestine.  The  last  category  includes  principally 
gall-stones,  which  either  have  become  awkwardly  impacted  in  the 
lumen  of  the  bowel  or  cause  obstruction  by  cohesion.  There  are 
on  record  a  number  of  instances  in  which  masses  of  spool-worms 
have  obstructed  the  lumen  of  the  bowel.  Rarely  intestinal  concre- 
tions— enteroliths — act  as  the  cause  of  obstruction  of  the  bowel. 

Among  the  parietal  causes  of  stenosis  and  obstruction  of  the 
bowel  cicatrices  and  neoplasms  may  first  be  mentioned.  Not  all 
ulcerative  and  cicatricial  processes  lead  with  the  same  degree  of 
frequency  to  stenosis  of  the  bowel.  Such  a  condition  occurs  but 
rarely  in  association  with  catarrhal  and  typhoid  ulceration  ;  but 
somewhat  more  frequently  in  the  case  of  tuberculous  ulcers ;  still 
more  dangerous  are  dysenteric  and  syphilitic  cicatrices.  Among 
intestinal  neoplasms  carcinomata  should  first  be  mentioned  ;  there 
may  also  be  sarcomata,  polypi,  at  times  also  lipomata  and  ade- 
nomata. Stenosis  of  the  bowel  may  be  due  to  hemorrhoids. 
Rarely  it  occurs  as  a  result  of  echinococcus  of  the  intestinal  wall. 
Displacements  of  the  boicel  often  give  rise  to  stenosis  or  obstruction. 
The  importance  of  invagination  of  the  bowel  has  already  been  dis- 
cussed in  the  preceding  section.  Incarcerated  hernia  deserves 
especial  consideration  by  reason  of  the  frequency  of  its  occur- 
rence. The  incarceration  may  involve  an  external  or  an  internal 
hernia.  In  the  latter  event  either  loops  of  bowel  enter  abnormal 
fissures,  such  as  are  known  to  occur  in  the  mesentery  and  the 
omentum,  and  also  in  the  round  ligament  of  the  uterus ;  or,  in 
consequence  of  jirevious  peritonitis,  bands  or  adhesions  have 
formed  between  the  abdominal  viscera  and  the  abdominal  wall, 
beneath  which  loops  of  bowel  find  their  way  and  are  incarcerated. 
There  are  besides  a  considerable  numl)er  of  internal  hernial  open- 
ings, in  which  loops  of  bowel  may  be  incarcerated.  Among  these 
varieties  of  hernia  may  be  mentioned  the  duodenojejunal,  intra- 
epiploic,  cecal,  intersigmoid,  iliacosub fascial,  anterior  retroperito- 


STENOSIS  AND   OBSTRUCTION  OF  THE  BOWEL         277 

neal,  hernia  into  the  vaginal  tunic  of  the  testicle  and  the  broad 
ligament  of  the  uterus,  and  diaphragmatic  hernia.  The  last  may- 
be congenital  or  be  acquired  through  traumatism. 

An  especial  variety  of  obstruction  of  the  bowel  results  from  twist- 
ing of  the  intestine  (volvulus),  axial  rotation  of  the  bowel,  and  the 
formation  of  a  knot.  The  longer  and  the  more  mobile  the  mesen- 
tery of  a  portion  of  bowel  the  more  readily,  naturally,  will  twisting 
and  axial  rotation  take  place.  Such  conditions  develop  with  especial 
frequency  at  the  sigmoid  flexure  of  the  descending  colon,  as  this  part 
of  the  bowel  turns  upon  the  axis  of  its  mesentery,  which,  while 
long,  is  narrow  at  its  attachment.  At  times  several  loops  of  bowel 
surround  others  in  the  form  of  a  knot,  and  thus  obstruct  the  lumen 
of  the  latter.  Most  commonly  the  sigmoid  flexure  is  twisted  about 
dependent  loops  of  ileum.  A  diverticulum  of  Meckel  or  the 
vermiform  appendix  may  form  a  knot-like  constriction  around 
adjacent  loops  of  bowel  and  render  these  impermeable.  Natur- 
allv,  it  may  happen  that  such  a  diverticulum  or  the  vermiform 
appendix  has  become  adherent  with  its  free  extremity  to  the 
abdominal  wall  or  to  other  abdominal  viscera,  and  that  loops 
of  intestine  enter  the  interval  and  become  obstructed.  So-called 
paralytic  ileus  should  also  be  mentioned  here;  its  production  is 
dependent  upon  the  fact  that  the  musculature  of  the  intestine  is 
paralvzed  throughout  a  limited  extent,  and  is  therefore  incapable 
of  propelling  the  intestinal  contents  onward.  This  condition  has 
been  observed  to  occur  in  association  with  chronic  diseases  of  the 
brain  and  the  spinal  cord,  with  peritonitis  and  perityphlitis,  and 
after  celiotomy  and  the  replacement  of  incarcerated  hernia. 

Among  the  extra-intestinal  causes  of  stenosis  and  obstruction 
of  the  boivel  may  be  included  all  'constrictions  due  to  pressure, 
and  which  are  usually  dependent  upon  diseases  of  the  adjacent 
viscera.  Naturally  loops  of  intestine  may,  by  reason  of  fecal 
accumulation  or  of  the  presence  of  a  neoplasm,  exert  mutual  press- 
ure on  one  another,  and  thus  cause  obstruction  of  the  bowel. 
Tumors  and  displacements  of  the  liver,  spleen,  or  kidney,  marked 
increase  in  the  size  of  the  pancreas,  neoplasms  of  the  omentum, 
the  uterus,  the  ovaries,  and  the  bladder,  parametritic,  perimetritic, 
and  peritonitic  exudates,  the  impregnated  and  retrodisplaced 
uterus,  these  all  are  capable  of  exerting  pressure  upon  the  intes- 
tine. At  times  stenosis  of  the  bowel  has  been  observed  in  cases 
of  prostatic  hypertrophy,  and  in  consequence  of  the  presence  of 
uterine  pessaries.  The  disorder  occurs  most  commonly  in  men. 
It  may  develop  at  any  time  of  life,  although  age  has  a  certain 
influence  upon  the  nature  of  the  causative  factors.  Thus,  invag- 
ination of  the  bowels  occurs  with  especial  frequency  in  childhood, 
and  carcinoma  of  the  intestine,  on  the  other  hand,  in  the  aged. 

Anatomic  Alterations. — The  bodies  of  those  dead  from 
stenosis  or  obstruction  of  the  bowel  are  characterized  by  unusual 


278  DIGESTIVE  ORGANS 

size  of  the  abdomen.  The  intestines  above  the  point  of  obstruc- 
tion are  greatly  distended  with  gas,  and  exhibit  a  tendency  to 
escape  through  the  opening  made  in  the  abdomen.  Peritonitis 
often  develops,  giving  rise  to  numerous  adhesions  between  differ- 
ent portions  of  the  intestine,  and  in  conjunction  with  marked  in- 
testinal nieteorism  often  rendering  extremely  difficult  the  deter- 
mination of  the  alterations  present.  In  accordance  with  the 
marked  accumulation  of  gas  in  the  intestine  the  diaphragm  is  at 
quite  a  high  level,  and,  in  addition  to  the  diaphragm,  the  liver, 
the  stomach,  the  spleen,  the  lower  border  of  the  lung,  and  the 
heart,  are  greatly  displaced  upward  into  the  thoracic  cavity.  The 
bodies  of  those  dead  from  intestinal  obstruction  are  generally 
greatly  emaciated,  and  the  face  appears  sunken  and  furrowed. 
The  more  deeply  situated  the  obstruction  the  greater  the  extent 
of  bowel  involved  in  the  changes  described.  The  intestine  just 
above  the  point  of  obstruction  is  greatly  distended.  Upon  the 
mucous  membrane  more  or  less  extensive  losses  of  tissue  are  not 
rarely  observed,  and  these  are  designated  fecal  or  stercoral  ulcers. 
They  are  probably  caused  less  by  the  mechanical  irritation  of  the 
feces,  as  is  generally  stated,  than  by  chemic  irritation,  and  espe- 
cially by  the  great  multiplication  of  bacteria  (Bacterium  coli  com- 
mune) capable  of  exciting  inflammation,  as  I  have  observed  them 
also  in  the  presence  of  perfectly  liquid  intestinal  contents.  As 
early  as  the  second  week  of  stenosis  of  the  bowel  an  increase  in 
the  thickness  of  the  musculature  of  the  bowel  takes  place,  a  kind 
of  functional  hypertrophy,  which  is  due  not  to  increase  in  the 
number  of  muscle-cells,  but  to  their  increase  in  size.  The  por- 
tion of  bowel  beyond  the  obstruction  ajjpears  narrow  and  collapsed. 
The  constricted  or  obstructed  portion  of  bowel  itself  frequently 
exhibits  inflammatory  and  even  necrotic  alterations.  Rupture  of 
the  bowel  may  take  place  at  this  point.  At  times,  however,  this 
accident  occurs  also  above  the  point  of  obstruction,  as  a  result  of 
excessive  distention  of  the  bowel  by  gas  and  stagnating  fecal  matter. 
Symptoms  and  Diagnosis. — The  si/mpfoms  of  ohsfruciion 
of  the  bowel  are  manifested  as  a  rule  in  obstinate  constipation. 
The  longer  it  has  persisted  the  more  do  the  patients  complain  of 
distention  of  the  abdomen  and  a  sense  of  tension.  Palpitation  of 
the  heart,  dyspnea,  a  sense  of  fear,  and  fulness  of  the  head  idso 
readilv  develop.  Xot  rarely  the  intesfiiia/  movements  above  the 
point  of  constriction  are  so  active  as  not  only  to  give  rise  to  loud 
rumbling — borborygmi,  but  they  may  also  be  visible  beneath  the 
abdominal  wall  as  alternately  protruding  and  receding  loops. 
Should  liquid  contents  be  forced  through  the  constriction,  sounds 
are  sometimes  heard  resembling  those  produced  when  fluid  is 
driven  through  a  syringe.  AVhen  the  large  intestine  is  the  seat 
of  stenosis  the  fecal  discharges  frequently  acquire  a  peculiar  shape. 
Small,  abbreviated  cylindric  masses  occur,  presenting  the  appear- 


STENOSIS  AND   OBSTRUCTION   OF  THE  BOWEL  279 

ance  of  coffee-beans,  or  the  fecal  discharges  of  the  sheep  or  the 
goat.  The  same  variety  of  feces  occurs  also  in  cases  of  inanition 
and  of  constipation  when  the  latter  is  dependent  upon  spasm  of 
the  musculature  of  the  bowel.  The  feces  may  also  exhibit  gutter- 
like depressions,  as,  for  instance,  when  intestinal  polypi  are  present. 
If  the  fecal  matter  be  forced  through  the  constricted  area,  most 
severe  abdominal  pain  is  often  produced,  which  may  cause  syncope 
and  general  clonic  muscular  spasm.  Although  constipation  is  the 
rule  in  cases  of  constriction  of  the  bowel,  diarrhea  is  by  no  means 
rare.  This  may  result  from  the  maintenance  by  the  stagnating 
fecal  material  of  a  chronic  catarrh  of  the  intestinal  mucous  mem- 
brane above  the  point  of  constriction.  It  is  noteworthy  that  the 
thin  stools  often  contain  unusually  hard  masses  of  fecal  matter. 
At  times  blood  is  found  in  the  stools,  and  its  appearance  is  to  be 
explained  by  mechanical  injuries  inflicted  by  the  fecal  matter,  and 
in  other  instances  by  tissue-disintegration. 

In  order  to  determine  the  seat  of  constriction  of  the  bowel  con- 
sideration should  be  given  to  the  degree  of  abdominal  distention, 
for  the  more  deeply  situated  the  constriction  the  greater  will  be 
the  abdominal  distention.  If  intestinal  movements  are  visible,  the 
point  at  which  these  are  especially  active  and  regularly  terminate 
is  often  of  diagnostic  importance.  As  a  matter  of  course,  an  effort 
should  be  made  by  careful  palpation  through  the  abdominal  ivalls, 
the  vagina,  and  the  rectum,  to  reach  the  obstruction  directly.  Ex- 
amination of  the  rectum  with  a  sound,  and  an  injection  into  the 
bowel,  as  well  as  the  employment  of  a  rectal  speculum,  will  also 
yield  valuable  diagnostic  information.  A  careful  history  and  a 
knowledge  of  the  mode  of  development  of  the  disorder  are  also 
important.  Thus,  for  instance,  attention  should  be  directed  to 
preceding  dysentery  and  syphilis,  to  tuberculous  alterations,  to 
the  state  of  the  bowels,  to  sudden  or  gradual  development,  and 
the  like.  In  this  way  the  exciting  cause  of  the  disorder,  and 
from  this  not  rarely  also  its  seat,  can  be  determined. 

The  course  of  stenosis  of  the  bowel  may  be  terminated  within  a 
few  hours,  or  it  may  be  extended  over  years,  in  accordance  with 
the  nature  of  tlie  causative  factors  and  the  care  observed  by  the 
patient  with  regard  to  diet  and  to  regularity  in  movement  of  the 
bowels.  One  of  the  most  important  dangers  consists  in  the  fact 
that  the  constriction  may  progress  to  occlusion  of  the  bowel. 
This  may  develop  gradually  or  occur  suddenly,  as,  for  instance, 
from  the  ingestion  of  indigestible  articles  of  food,  which  may 
accumulate  above  the  point  of  constriction  like  a  valve,  or  from 
constipation.  Naturally  most  cases  of  obstruction  of  the  boicel  or 
ileus  begin  suddenly.  Not  rarely  heavy  lifting,  the  ingestion  of 
excessively  cold  or  of  indigestible  food,  a  fall  or  a  blow  upon  the 
abdomen,  and  the  like  are  assigned  as  causes.  At  times  the  dis- 
order sets  in  with  severe  pain  in  the  abdomen. 


280  DIGESTIVE  ORGANS 

The  principal  symptoms  of  obstruction  of  the  bowel  are  reten- 
tion of  fecal  matter  and  of  intedinal  gases,  and  fecal  vomiting — mis- 
erere. Naturally,  it  may  happen  at  the  beginning  of  the  disease 
that  repeated  thin  stools  are  voided,  and  these,  in  cases  of  invagina- 
tion of  the  bowel,  may  partake  of  a  mucous  and  bloody  character, 
but  soon  thereafter  most  obstinate  constipation  sets  in.  Like  the 
feces,  gas  also  may  be  unable  to  pass  tlie  obstructed  portion  of 
bowel,  and  the  patient  cannot  discharge  flatus.  Naturally,  if  air 
is  introduced  into  the  bowel  in  addition  to  fluid  in  the  process  of 
making  an  intestinal  infusion,  it  may  happen  that  the  air  is  ex- 
pelled in  the  form  of  flatus,  a  phenomenon  without  significance 
that  should  not  be  referred  to  a  restoration  of  the  permeability 
of  the  bowel.  The  vomited  matters  consist  at  first  only  of  gastric 
contents,  and  accordingly  their  appearance  varies  with  accidental 
conditions.  After  the  stomach  has  been  emptied  the  greenish 
bilious  contents  of  the  small  intestine  are  voided  in  the  act  of 
vomiting.  Finally,  vomiting  of  fecal  matter  occurs.  This  is 
conspicuous,  in  the  first  place,  from  its  marked  fecal  odor.  Usu- 
ally it  consists  of  a  yellowish,  thin  mass,  which  often  contains 
light-yellow  or  brownish-yellow  fragments  of  fecal  matter.  The 
presence  of  formed  fecal  nodules  is  an  exceptional  occurrence. 
The  deeper  the  situation  of  obstruction  of  the  liowel,  the  more 
abundant  and  the  more  fecal  does  the  vomited  matter  become, 
for  the  greater  will  be  the  contents  of  the  intestine,  and  the  fecal 
matter  acquires  its  distinctive  character  in  the  deeper  portions  of 
the  bowel. 

In  the  past  various  explanations  were  offered  for  the  occurrence  of  fecal 
vomiting.  At  present  it  is  assumed  not  that  it  is  dependent  upon  anti- 
peristaltic intestinal  movement,  but  that  the  intestinal  contents  endeavor 
to  escape  backward  from  the  obstruction  in  consequence  of  the  pressure 
resulting  from  the  peristaltic  intestinal  movement. 

On  examination  distention  of  the  abdomen,  horborygmi,  and 
active  peristaltic  intestinal  movements  are  observed  for  the  same 
reasons  as  in  cases  of  intestinal  constriction.  Xot  rarely  cer- 
tain loops  of  intestine  appear  as  unusually  thick  and  tensely  dis- 
tended structures  lying  one  upon  another.  Careful  palpation  of 
the  abdomen,  particularly  of  all  external  hernial  orifices,  and 
thorough  examination  through  the  vagina  and  the  rectum  should 
never  be  omitted,  in  order  to  determine,  if  possible,  the  situation 
and  possibly  also  the  nature  of  the  obstruction.  The  deleterious 
influence  of  intestinal  obstruction  upon  the  general  condition  is 
most  striking.  The  features  of  the  patient  soon  become  sunken, 
and  he  often  speaks  in  a  faint  and  high-pitched  voice,  like  a 
cholera-patient.  The  bodily  temperature  is  frequently  subnor- 
mal, and  the  pulse  small  and  running.  After  severe  vomiting 
the  skin  loses  its  turgor,  remains  ele,vated  in  folds,  and  feels  moist 
and  cold  like  that  of  an  amphibious  animal.     The  urine  is  dimin- 


STENOSIS  AND   OBSTRUCTION  OF  THE  BOWEL         281 

ished  in  amoimt  and  dark  in  color.  Examination  of  the  urine  for 
indican  is  of  importance,  for  if  peritonitis  be  absent  and  carci- 
noma is  not  the  cause  of  the  obstruction,  increased  elimination 
of  indican  is  indicative  of  obstruction  of  the  small  intestine. 

For  the  demonstration  of  indican  the  test  of  JafFe  may  be  employed. 
To  this  end  a  test-tube  is  half-filled  with  urine,  the  remaining  half  with 
hydrochloric  acid,  and  from  1  to  5  drops  of  fresh  concentrated  chlorinated 
lime  are  added.  After  the  addition  of  each  drop  the  opening  of  the  tube 
should  be  closed  with  the  thumb,  and  the  tube  inverted  several  times. 
The  addition  of  chlorinated-lime  solution  is  suspended  when  a  deep-blue 
discoloration  of  the  urine  no  longer  takes  place.  Chlorinated  lime  in 
excess  would  cause  a  diminution  in  the  intensity  of  the  color.  An  increase 
in  the  amount  of  indican  in  the  urine  will  be  indicated  by  the  fact  that  the 
urine  acquires  a  violet-red,  bluish,  or  deep  blue-black  color.  Obstruction 
of  the  small  intestine  gives  rise  to  an  increase  in  the  amount  of  indican  in 
the  urine  in  consequence  of  interference  with  intestinal  digestion  and  in- 
creased fermentation  of  proteid  bodies  in  the  contents  of  the  bowel.  The 
substances  of  the  indigo-group  are  derived  from  proteid  decomposition  in 
the  intestinal  contents.  For  the  same  reason  the  urine  contains  an  abun- 
dance of  phenol  and  ethereal  sulphates. 

The  duration  of  obstruction  of  the  bowel  may  at  times  extend 
over  only  a  few  hours,  death  occurring  amid  manifestations  of 
shock.  In  other  instances  the  disorder  persists  for  days,  and  even 
for  more  than  a  week.  Death  results  in  consequence  of  either 
progressive  exhaustion  or  complications,  of  which  peritonitis  and 
rupture  of  the  bowel  with  secondary  perforative  peritonitis  are  the 
most  common.  Not  rarely  inspiraiion-pneumonia  develops,  be- 
coming converted  into  pulmonary  abscess  and  gangrene  of  the 
lung,  and  resulting  from  the  aspiration  of  vomited  matters.  The 
condition  is  often  unrecognized  during  life,  for  the  reason  that 
frequent  raising  of  the  patient  to  the  erect  posture  for  the  examina- 
tion of  the  posterior  portion  of  the  lungs  is  avoided  on  account 
of  weakness.  In  some  cases  rupture  of  the  bowel  takes  place 
into  an  encapsulated  cavity,  and  there  forms  a  fecal  abscess,  with 
which  septicopyemia  may  be  associated.  It  may  also  happen 
that  after  previous  adhesion  of  the  intestine  with  the  abdominal 
walls  rupture  takes  place  externally,  with  the  formation  of  a 
fecal  fistula.  A  sort  of  natural  cure  takes  place  in  rare  instances 
from  the  formation  of  adhesions  between  loops  of  intestine  above 
and  below  the  point  of  obstruction,  with  the  establishment  of 
communication  through  a  fistula — so-called  bimucous  intestinal 
fistula.  Relief  from  ileus  may  be  recognized  from  the  fact  that 
flatus  again  escapes,  bowel-movements  are  resumed,  and  the  vomit- 
ing ceases.  The  escape  of  flatus  is  of  especial  importance,  as  the 
residue  of  fecal  matter  below  the  point  of  constriction  might  give 
rise  to  a  bowel-movement.  Some  persons  pass  through  several 
attacks  of  intestinal  obstruction  in  the  course  of  their  lives.  At 
times  the  causative  factors  are  obvious  (fecal  accumulation,  gall- 


2<S2  DIGESTIVE  ORGANS 

stones,  incarcerated  hernia,  invagination),  while  in  other  instances, 
on  the  contrary,  it  is  impossible  to  discover  the  causative  factors. 

Obstruction  of  the  bowel  as  such  is  usually  easy  of  diaf/aosii, 
for  constipation,  failure  of  gas  to  escape  from  the  bowd,  and  fecal 
voiititiiif/  are  readily  recognizable  and  reliable  symptoms.  On  the 
other  hand,  insurmountable  difficulties  often  arise  with  regard  to 
the  determination  of  the  nature  and  the  seat  of  the  obstruction. 
Ill  the  presence  of  syinptoins  of  obstruction  of  the  bowel  careful  ex- 
amination of  all  hernial  openiiu/s  for  incarcerated  hernia  should  never 
he  omitted.  I  have  knowledge  of  many  instances  in  which  even 
so-called  first  authorities  in  the  domain  of  internal  medicine  had 
neglected  this  rule.  A  harmless  operation  for  hernia  at  the  proper 
time  would  have  saved  the  patient,  who  otherwise  dies  subse- 
quently in  consequence  of  gangrene  of  the  incarcerated  loop  of 
bowel,  peritonitis,  and  septicemia.  If  an  external  incarcerated 
hernia  can  be  excluded,  it  will  be  possible  in  some  cases  to  form 
an  opinion  as  to  the  anatomic  nature  of  the  obstruction  from  the 
history  (previous  constipation,  gall-stones,  tuberculosis,  syphilis, 
dysentery,  previous  peritonitis,  etc.).  The  age  of  the  patient  is 
deserving  of  consideration,  as  sudden  obstruction  of  the  bowel  in 
children  is  frequently  dependent  upon  invagination  and  in  the  aged 
upon  carcinoma.  In  cases  of  intestinal  invagination  the  raucous 
and  bloody  stools  at  the  onset  of  the  disease  are  of  diagnostic  import- 
ance. Palpation  of  the  abdomen  and  examination  of  the  abdom- 
inal cavity  tJirough  the  vagina  and  the  rectum  may  also  furnish 
valuable  diagnostic  information  (a  longitudinal  tumor  in  cases  of 
invagination,  cicatricial  stenosis  or  nodular  carcinomatous  new- 
growth  in  the  rectum,  retrodisplacement  of  the  uterus,  and  the 
like).  In  other  instances,  whether  axial  rotation,  knot-formation, 
or  internal  strangulation  of  the  bowel  is  present  can  scarcely  be 
determined  with  any  degree  of  probability  during  life.  The  dif- 
ferentiation between  paralytic  and  mechanical  ileus  in  consequence 
of  peritonitis  and  perityphlitis  remains  as  yet  among  the  unsolvable 
problems. 

In  the  recognition  of  the  seat  of  obstruction  of  the  bowel  the 
local  intestinal  condition  is  important  (palpable  constriction  in 
the  rectum,  palpable  tumors,  increased  peristaltic  movement  only 
to  a  certain  jiortion  of  the  bowel);  besides,  considerable  import- 
ance is  to  be  attached  to  the  amount  of  indican  in  the  urine,  for 
if  this  be  increased  it  indicates  an  obstruction  of  the  small  intes- 
tine, if  peritonitis  be  not  present  and  carcinoma  can  be  excluded. 
Less  relial)le  from  the  diagnostic  standpoint  is  distention  of  the 
abdomen,  although  it  is  true  that  this  is  the  greater  the  deeper  the 
seat  of  the  obstruction  in  the  bowel. 

In  those  rare  cases  in  which,  especially  at  the  onset  of  obstruction  of 
the  bowel,  severe  diarrhea  and  vomiting  occur,  error  has  at  times  been 
committed  in  confounding  the  condition  with  Asiatic  cholera  and  poisoning 


STENOSIS  AND   OBSTRUCTION  OF  THE  BOWEL         283 

(arsenic,  antimony).     The  diagnosis  of  cholera  can  at  present  be  made 
bacteriologically,  and  in  cases  of  poisoning  the  history  is  of  importance. 

Prognosis. — The  prognosis  of  stenosis  and  obstruction  of  the 
bowel  is  unfavorable  when  the  causative  conditions  are  irremedi- 
able.    Even  under  other  conditions  also,  however,  it  is  grave. 

Treatment. — Prophylactic  measures  are  indicated  especially 
in  the  presence  of  stenosis  of  the  bowel.  The  diet  should  be  so 
regulated  that  neither  the  fecal  masses  should  be  too  large  nor 
constipation  should  arise.  Besides,  obstructions  that  are  removable 
should  be  corrected,  as,  for  instance,  stricture  of  the  rectum — an 
indication  that  is  included  in  the  causal  treatment.  If  symptoms 
of  intestinal  obstruction  have  appeared,  rest  in  bed,  a  liquid  diet, 
and  opium  should  be  prescribed  : 

R  Powdered  opium,  0.02  (J  grain)  ; 

Sugar,  0.3  (4i  grains). — M. 

Make  10  such  powders. 
Dose :  1  powder  every  two  hours. 

In  the  second  place,  causal  treatment  should  be  carried  out. 
Strangulated  external  hernia  should  be  replaced  or  released  by  ab- 
dominal section.  The  clinical  picture  of  intestinal  obstruction  may 
persist  after  reposition,  either  because,  in  replacement  en  masse, 
actual  release  of  the  constriction  has  not  been  effected,  or  because 
the  incarcerated  loop  of  intestine  has  been  paralyzed,  with  resulting 
paralytic  ileus.  Obstruction  of  the  bowel  in  consequence  of  fecal 
accumulation  can  be  relieved  by  irrigation  of  the  bowel  wath  ice- 
water,  repeated  at  intervals  of  two  hours.  The  first  injections 
are  frequently  without  effect,  the  fluid  returning  clear,  because  the 
lowermost  fecal  matters  are  of  stony  hardness  and  must  first  be 
softened.  At  times  it  even  becomes  necessary  first  to  remove  a 
number  of  fecal  masses  from  the  rectum  with  the  fingers  before 
the  column  of  fecal  matter,  situated  higher  up,  can  escape,  some- 
times in  remarkable  amount.  Foreign  bodies  in  the  rectum,  also, 
must  be  removed  with  the  fingers,  etc.  Should  there  be  no  indi- 
cation for  causal  treatment — as,  for  instance,  if  the  condition 
causative  of  the  obstruction  be  not  recognized — attempts  should 
be  made  to  restore  the  permeability  of  the  bowel  by  intestinal 
injections  of  cold  water,  repeated  several  times  daily.  Instead  of 
injections  of  water,  enemata  of  air  or  of  carbon  dioxid  have  also 
been  employed.  In  the  presence  of  severe  fecal  vomiting  the 
stomach  should  be  washed  out  several  times,  as  the  symptoms  of 
intestinal  obstruction  are  said  to  have  disappeared  after  irrigation 
of  the  stomach.  By  some,  mercury  in  tablespoonful-doses  up  to 
1000  grams  has  been  successfully  employed.  In  a  patient  with 
ileus,  operation  on  whom  had  already  been  decided  upon,  I 
observed  the  bowels  to  be  moved  and  recovery  to  take  place  after 
all  other  measures  had  been  attempted  without  success,  as  a  result 


284  DIGESTIVE  ORGANS 

of  the  application  of  one  pole  of  the  faradic  current  in  the  rec- 
tum, while  the  other  was  placed  upon  the  abdominal  wall. 

Actually  certain  relief  can  be  expected,  however,  only  from 
surgical  intervention;  but  this  should  not  be  deferred  until  in- 
flanimatiou  and  gangrene  of  the  obstructed  portion  of  bowel 
or  general  peritonitis  has  developed.  One  plan  to  be  pursued 
consists  in  opening  the  abdomen,  finding  and  removing  the  ob- 
struction, and  freeing  the  bowel,  while  another  consists  in  the 
establishment  of  an  intestinal  fistula  above  the  point  of  occlusion. 
Further,  the  search  for  an  oljstruction  is  often  extremely  difficult 
on  account  of  the  great  distention  of  the  intestine  with  gas.  If  it 
be  impossible  to  find  the  obstruction,  one  will  be  compelled  to  be 
satisfied  w^itii  the  establishment  of  a  preternatural  anus.  This, 
however,  will  by  no  means  remove  all  sources  of  danger,  as  in- 
flammation and  gangrene  of  the  obstructed  portion  of  bowel  may 
yet  result  and  give  rise  to  general  peritonitis.  At  times,  further, 
the  bowel  has  been  observed  to  become  again  patulous  a  short  time 
after  the  establishment  of  a  fecal  fistula,  so  that  subsequently  it 
became  possible  to  close  the  fistula.  Clinicians  have  stated  that 
sometimes  after  punetiire  of  tJie  bowel  the  symptoms  of  intestinal 
obstruction  disappear  ;  but  surgeons  will  probably  not  look  favor- 
ably upon  this  kind  of  intestinal  surgery — and  properly  so,  in  our 
opinion. 

HEMORRHOIDS. 

Ktiology. — Hemorrhoids  consist  in  varicose  dilatation  of  the 
hemorrhoidal  veins.  They  occur  with  extreme  frequency,  because 
stasis  of  blood  in  the  hemorrhoidal  veins  is  greatly  favored  by  the 
dependent  position  of  the  veins  and  their  freedom  from  valves. 
The  observation  that  hemorrhoids  are  common  in  som'e  families 
and  develop  under  such  conditions  upon  slight  provocation,  appears 
to  indicate  that  at  times  a  congenital  li-ant  of  resistance  in  the  trails 
of  the  veins  is  also  probably  operative.  The  causes  of  the  stasis  are 
at  times  local  and  at  other  times  general.  Among  the  local  causes 
may  be  included  constipation,  carcinoma  of  the  rectum,  chronic 
jyroctitis,  prostatic  hypertrophy,  retrod isjylacement  of  the  iderus,  neo- 
plasms of  the  iderns,  and  pregnancy.  Long-continued  sitting  and 
riding  also  favor  the  development  of  hemorrhoids.  The  disorder 
is  therefore  encountered  with  jxirticular  frequency  in  certain 
classes,  as,  for  instance,  students,  shoemakers,  cavalrymen.  Not 
rarely  the  affection  develops  in  persons  who  indulge  in  sexual 
excesses,  or  preferably  sit  ujjon  upholstered  furniture,  probably  in 
consequence  of  diversion  of  an  excessive  amount  of  blood  to  the 
sexual  organs  and  their  vicinity.  Hemorrhoids  are  a  frequent 
sequel  of  stasis  in  the  porttd  vein,  and  they  develoji  often  therefore 
in  cases  of  thrombosis  of  this  vein,  cirrhosis  of  the  liver,  and  also 
other  diseases  of  this  organ.     Frequently  they  depend  upon  gen- 


HEMORRHOIDS  285 

eral  venous  stasis.  They  occur,  therefore,  in  cases  of  chronic  dis- 
ease of  the  heart  and  of  the  respiratory  organs.  I  have  observed 
them  also  in  a  number  of  instances  in  persons  who  play  upon 
wind-instruments,  in  glass-blowers,  and  in  those  who  carry  heavy 
loads.  Obese  individuals,  \\\\o  are  inclined  to  indulge  excessively 
in  the  pleasures  of  the  table,  often  suffer  from  hemorrhoids. 

As  a  rule,  hemorrhoids  do  not  develop  before  adidt  life,  as  may 
be  readily  understood  from  the  nature  of  the  causative  factors. 
Men  suffer  more  commonly  than  women.  The  disease  is  especially 
common  in  the  Orient,  being  favored  perhaps  by  sexual  excesses. 

Anatomic  Alterations. — A  distinction  is  made  between 
external  and  internal  hemorrhoids,  accordingly  as  the  venous  dila- 
tation is  situated  without  the  sphincter  ani  muscle,  and  is  directly 
exposed  to  ocular  inspection,  or  above  the  sphincter  muscle  in  the 
lower  portion  of  the  rectum.  In  rare  instances  the  mucous  mem- 
brane of  the  descending  colon  is  found  covered  with  bluish-black 
varices  up  to  the  sigmoid  flexure  of  the  colon.  At  times  hemor- 
rhoids form  single  nodules  from  the  size  of  a  pea  to  that  of  a 
walnut,  and  even  that  of  an  apple.  Sometimes  such  nodules  are 
disposed  close  together  in  a  circular  manner.  At  times  adjacent 
nodules  have  coalesced,  and  have  formed  a  sort  of  venous  cavern- 
oma.  Further,  hemorrhoidal  dilatations  diminish  greatly  in  size 
as  a  rule  after  death.  The  adjacent  mucous  membrane  of  the 
rectum  is  generally  in  a  state  of  chronic  catarrh,  with  marked 
thickening  of  the  submucosa.  At  times  thrombi  have  formed  in 
some  of  the  venous  dilatations,  and  these  subsequently  undergo 
calcification.  These  bodies  of  stony  hardness  are  designated  vein- 
stones or  phleboliths. 

Symptoms  and  Diagnosis. — Many  persons  believe  that 
they  suffer  from  hemorrhoids  when  these  are  not  present,  while 
others  have  hemorrhoids,  but  are  free  from  symptoms  and  without 
intimation  of  the  existence  of  the  disorder.  The  single  certain 
symptom  is  the  demonstration  of  hemorrhoidal  nodules,  which,  if 
they  be  external,  can  be  seen  directly  on  inspection  of  the  anus  to 
consist  of  more  or  less  tensely  distended  bluish  nodules  of  varied 
size,  and  if  they  be  internal  can  be  felt  by  means  of  the  finger 
introduced  into  the  rectum  as  soft  nodular  elevations.  Digital 
examination  of  the  rectum  should  never  be  omitted  in  order  to 
determine  positively  whether  internal  hemorrhoids  exist  at  all,  or 
internal  hemorrhoids  are  present  together  with  external  hemor- 
rhoids. The  attention  of  some  patients  is  first  directed  to  the 
presence  of  this  disorder  by  the  occurrence  of  hemorrhoidal  bleed- 
ing, and  this  also  is  frequently  observed  only  accidentally  from 
the  fact  that  the  paper  used  for  cleansing  the  anal  region  after  a 
bowel-movement  feels  slippery  and  on  examination  is  found  to  be 
streaked  with  blood.  When  the  hemorrhage  is  more  copious  the 
body-linen  and  the  bed-linen  may  be  saturated  with  blood.     The 


28G  DIGESTIVE  ORGANS 

occurrence  of  the  hemorrhage  is  not  rarely  preceded  by  peculiar 
manifestations,  which  were  formerly  designated  as  hemorrhoidal 
molimina.  Among  these  are  a  sense  of  fulness  of  the  head,  of  pulsa- 
tion in  the  head,  iieadache,  vertigo,  palpitation  of  the  heart,  a 
sense  of  fear  and  oppression,  a  sensation  of  tickling  or  of  tension 
at  the  anus,  a  sense  of  beating  in  the  anal  region,  and  the  like. 
These  disturbances  generally  cease  as  soon  as  the  hemorrhage  has 
begun,  and  the  niajority  of  patients  become  conscious  of  a  sense 
of  relief  and  freshness  after  the  termination  of  the  bleeding.  They 
anticipate  with  satisfaction  the  occurrence  of  such  a  hemorrhage, 
which  they  consider  as  a  beneficial  discharge  of  impure  fluids,  and 
for  this  reason  the  designation  "golden  vein"  was  formerly  em- 
ployed instead  of  hemorrhoids.  AVlien  opportunity  is  afforded 
for  examining  daily  patients  Mith  external  hemorrhoids  it  will 
frequently  be  found  that  a  hemorrhoidal  nodule  progressively 
increases  in  size.  The  tension  of  the  overlying  skin  becomes 
increased,  the  skin  becomes  thinned,  and  finally  it  and  the  wall 
of  the  vein  rupture,  and  blood  is  discharged  externally.  The 
statement  that  the  hemorrhages  occur  at  definite  intervals,  as  does 
menstruation,  is  incorrect.  Often  no  cause  for  the  occurrence  is 
apparent,  while  at  other  times  it  has  been  preceded  by  indulgence 
in  alcohol  or  sexual  excitement,  persistent  sitting,  or  excessive 
walking  and  riding.  The  amount  of  blood  lost  varies  exceedingly. 
It  is  of  exceptional  rarity  that  the  hemorrhage  is  so  profuse 
and  uncontrollable  that  life  appears  to  be  threatened.  Profound 
anemic  states,  with  their  varied  disorders,  especially  palpitation 
of  the  heart  and  dyspnea,  do,  however,  occur  with  frequency,  and 
require  treatment.  ISIucous  discharges  from  the  anus  that  some- 
times take  place  with  the  evacuation  of  fecal  matter  or  gas  have 
been  described  as  blind  or  mucous  hemorrhoids.  These  are,  how- 
ever, merely  the  manifestations  of  a  chronic  catarrh  of  the  rectum. 
At  times  they  constitute  the  only  symptom  in  patients  with  hem- 
orrhoids. "\Vhile  it  is  true  that  such  patients  are  often  depressed 
and  hvpochondriacal,  such  a  condition  is  to  be  attributed  to  the 
chronic  catarrh  of  the  rectum. 

Patients  sufPiM-ing  from  hemorrhoids  often  complain  of  pares- 
thesia in  the  anal  region,  especially  of  tickling  and  l)urning. 
There  is  also  often  a  sense  of  a  foreign  body  in  the  rectum,  par- 
ticularly in  walking.  Not  rarely  constipation  exists,  and  it  is 
necessary  in  each  case  to  determine  whether  this  be  a  cause  or  a 
consequence  of  the  hemorrhoids.  It  happens  but  rarely  that  hemor- 
rhoidal nodules  attain  such  a  consideral)le  size  as  to  give  rise  to 
constriction  or  obstruction  of  the  bou-el.  Internal  hemorrhoids  at 
times  protrude  from  the  anus,  particularly  with  movements  of  the 
bowel,  but  cannot  be  returned  because  they  are  incarcerated  by  the 
sphincter  ani  muscle.  Such  strangulation  of  hcmorrhoidcd  nodules 
gives  rise  to  intense  pain  in  the  anal  region,  so  that  even  strong 


HEMOBRHOWS  287 

individuals  writhe  and  groan  with  pain.  Usually  they  occupy  the 
lateral  decubitus,  with  the  lower  extremities  flexed  at  the  hip  and 
the  knee.  If  the  incarceration  he  not  speedily  removed,  inflam- 
mation and  gangrene  of  the  strangulated  nodules  take  place,  and 
consequent  absorption  of  the  exciting  agents  of  inflammation  into 
the  blood-stream  may  give  rise  to  septicopyemia.  Inflammation  of 
heiiiorrhoidal  nodules  also  occurs  at  times  independently  of  strangu- 
lation. Under  such  conditions  the  inflammatory  process  not  rarely 
extends  to  the  periproctal  connective  tissue,  with  the  development 
of  a  periproctal  abscess.  Accordingly  as  this  ruptures  externally 
or  internally  into  the  rectum,  or  in  both  directions  at  the  same 
time,  an  external,  an  internal,  or  a  complete  rectal  fistula  develops. 
Hemorrhoids  also  occasion  a  predisposition  to  fissures  or  tears  of 
the  anus.  Chronic  eczema  of  the  skin,  likewise,  develops  not  rarely 
in  the  neighborhood  of  the  anus. 

Hemorrhoids  may  undergo  complete  involution  if  the  causative 
conditions  are  removed,  as,  for  instance,  in  the  case  of  pregnancy. 
Often,  however,  the  causative  conditions  are  incurable,  so  that  the 
disorder  may  persist  throughout  the  whole  of  life  and  exhibit  only 
frecjuent  variations  in  course.  Although  the  diagnosis  of  hemor- 
rhoids is  easy,  it  may  be  equally  difficult  to  determine  the  causa- 
tive conditions.  In  persons  of  advanced  years  digital  examination 
of  the  rectum  for  carcinoma  should  never  be  omitted,  as  this  con- 
dition frequently  causes  hemorrhoids,  and  even  independently  of 
these  may  give  rise  to  mucous  and  l^loody  discharges  from  the 
rectum,  which  by  a  careless  diagnostician  might  be  at  once  attrib- 
nted  to  insig-nificant  and  harmless  hemorrhoids.  Should  there  be 
any  doubt  as  to  the  nature  of  outgrowths  at  the  anus  (condyloma, 
folds  of  skin,  epithelial  carcinoma),  puncture  with  a  sterilized 
needle  should  be  practised,  and  the  escape  of  a  few  drops  of  blood 
looked  for. 

Prognosis. — Hemorrhoids  constitute  an  annoying  rather  than 
a  dangerous  condition.  The  likelihood  of  cure  depends  upon  the 
curability  of  the  causative  factors. 

Treatment. — In  the  treatment  of  hemorrhoids  causal  therapy 
will  first  require  careful  consideration.  Persons  suffering  from 
hemorrhoids  should  be  especially  careful  to  secure  regular  evacua- 
tion of  the  bowels  and  to  cleanse  thoroughly  the  anal  region  after 
each  bowel-movement.  Active  pedestrianism  and  the  use  of  hard 
chairs  in  place  of  upholstered  furniture  should  be  recommended. 
Sexual  and  alcoholic  excesses  should  be  avoided.  If  the  causative 
factors  be  irremediable  or  if  hemorrhoids  cause  distress  by  reason  of 
their  size  or  of  hemorrhage,  or  of  incarceration  and  inflammation, 
they  can  only  be  removed  by  surgical  operation,  although  the  patient 
must  be  informed  that  they  may  recur  after  the  lapse  of  some  time. 
Operations  for  hemorrhoids  were  formerly  looked  upon  with  doubt 
justly  on  account  of  the  frequent  occurrence  of  septicopyemia. 


288  DIGESTIVE  ORGANS 

Various  procedures  have  been  recommended ;  for  instance,  liga- 
tion and  clamping  of  the  venous  nodule,  removal  by  means  of  the 
galvanucautery,  excision  of  the  nodule,  dilatation  of  the  anus,  and 
injection  of  carbol-glycerin.  Among  the  complications  hemor- 
rhoidal bleeding  does  not,  as  a  rule,  require  especial  intervention. 
If  incarceration  of  hemorrhoidal  nodules  occur,  an  effort  should  be 
made  to  return  them  into  the  rectum  by  means  of  gradual  pressure 
exerted  with  the  aid  of  a  clean  pad  dipped  in  oil.  Should  this 
fail  they  should  be  covered  with  a  tepid  solution  of  mercuric 
chlorid  (1  :  1000)  and  their  exfoliation  awaited.  The  treatment 
last  named  is  applicable  also  in  cases  of  inflainm,ation  of  hemor- 
rhoidal nodides  and  of  the  vicinity.  Periproctal  abscesses  require 
incision  with  the  knife. 


MELENA  OF  THE  NEWBORN. 

The  occurrence  of  bloody  vomiting  or  hematemesis,  and  of  intes- 
tinal hemorrhage  or  enterorrhagia,  in  the  newborn  is  known  as 
melsena  neonatorum.  At  times  the  condition  begins  with  hemat- 
emesis,  and  at  other  times  with  enterorrhagia.  It  may  also 
happen  that  perhaps  only  the  one  or  the  other  phenomenon  takes 
place.  The  disorder  is  rare,  but  is  attended  with  great  danger  of 
death  from  hemorrhage  and  exhaustion.  As  may  be  understood, 
the  condition  can  be  readily  recognized  from  its  conspicuous  symp- 
toms, but  care  must  be  observed  to  avoid  confounding  it  with  the 
presence  of  blood  that  has  been  swallowed  and  has  gained  entrance 
into  the  gastro-intestinal  canal  of  the  infant  during  birth,  or  from 
injured  nipples.  Causative  factors  can  at  times  not  be  elicited. 
Sometimes  parturition  has  been  abnormal,  or  there  has  been  some 
peculiarity  in  the  ligation  of  the  umbilical  cord.  In  some  cases 
the  condition  a})pears  to  be  a  sequel  of  septic  infection.  Recently 
melena  of  the  newborn  has  been  attributed  variously  to  injuries 
of  and  hemorrhage  into  the  brain  and  spinal  cord.  As  a  rule, 
ulcercdion  of  the  gastro-intestinal  mucous  membrane  is  found,  but 
nothing  definite  is  known  as  to  the  origin  of  this.  It  has  been 
attributed  to  embolic,  thrombotic,  and  mycotic  influences,  but  these 
are  all  underaonstrated  hypotheses.  Therapeutically  cold  fomenta- 
tions may  be  applied  to  the  abdomen  and  Malaga  wine  admin- 
istered in  drop-doses  to  avert  exhaustion. 

ENTEROPTOSIS. 

Displacement  of  the  bowel  preferably  involves  the  colon,  espe- 
cially its  transverse  portion,  whose  loops  may  thus  at  times  descend 
into  the  true  pelvis.  As  a  result  there  naturally  is  difficulty  in  the 
propulsion  of  the  intestinal  contents,  and  the  patients  complain  of 
constipation  and  digestive  disturbances  of  varied  kind.     The  con- 


IS  TESTIS  A  L  SEUEOSES  289 

(lition  can  be  recognized  by  distending  the  large  intestine  with  air 
or  large  amounts  of  water  through  the  anus,  and  pi'actising  per- 
cussion along  the  course  of  the  transverse  colon.  Enteroptosis  is 
usually  found  in  association  with  displacement  of  other  viscera,  and 
particularly  wandering  kidney,  both  conditions  Ijeiug  dependent 
upon  the  same  causes.  The  patients  are  frequently  pallid  and 
nervous  individuals. 

The  treatment  consists  in  improvement  of  the  general  nutri- 
tion, abdominal  massage,  the  wearing  of  an  abdominal  binder,  care 
to  secm'e  a  daily  evacuation  of  the  bowels,  and  the  correction  of 
displacement  of  otlier  abdcmiinal  viscera,  such  as  a  wandering 
kidney. 

INTESTINAL  NEUROSES. 

Less  is  known  concerning  intestinal  neuroses  than  concerning 
gastric  neuroses.  The  former  may  at  times  be  motor,  at  other 
times  secretors',  sensory,  or  vasomotor.  Mixed  intestinal  neuroses 
also  occur. 

MOTOR  INTESTINAL  NEUROSES. 

ATONY  OF  THE   INTESTINE. 

Ktiology. — Atony  of  the  intestine  may  also  be  designated 
relaxation  of  the  muscular  coat  of  the  intestine.  In  consequence, 
the  bowel  is  incapable  of  properly  propelling  its  contents  and  con- 
stijpation  results.  As  the  latter  not  rarely  persists  throughout  life, 
the  condition  has  also  been  designated  habitual  constipation.  Often 
the  disorder  is  hereditary  and  congenital,  and  possesses  the  charac- 
ters of  a  familial  disease.  In  other  cases  the  disease  is  acquired, 
in  consequence  of  previous  chloro-sis,  debilitating  diseases,  and 
central  neuroses  (hy.steria,  neurasthenia,  hypochondriasisj.  Xe- 
glect  of  intestinal  activity  also  is  followed  by  atr>ny  of  the  bowel. 
The  condition  is  therefore  frequently  observed  in  women  who  are 
in  the  habit  of  suppressing  the  desire  for  stool  in  order  not  to  be 
interrupted  in  their  work.  The  disorder  is  exceedingly  common, 
as  the  modern  mode  of  life  favors  its  development  in  marked 
degree.     It  is  not  rarely  riljservcd  in  pupils  at  school. 

Symptoms,  Diagnosis,  and  Prognosis. — Atony  of  the 
bowel  gives  rise  to  constipation,  so  that  the  patients  at  times  have 
a  bowel-movement  once  or  twice  a  week,  or  not  at  all  without  the 
emplovment  of  purgatives.  At  the  same  time  it  is  characteristic 
that  symptoms  are  wanting  indicative  of  anatomic  changes  in  the 
bowel.  When  the  bowels  are  moved,  excessive  expulsive  efforts 
must  be  made,  and  the  feces  are  dry,  hard,  and  black,  as  if  charred 
or  burned,  and  they  readily  cause  severe  pain  in  the  rectum  and 
the  anus  by  mechanical  iiTitation.  Injuries  of  the  mucous  mem- 
brane and  (generallv  small)  hemorrhages  may  also  occur.     The 

19 


290  DIGESTIVE  ORGANS 

longer  the  interval  between  the  bowel-movements  the  greater 
becomes  the  complaint  of  abdominal  distention,  disagreeable 
pressure,  and  even  of"  pain  in  the  abdominal  cavity,  and  the  like. 
The  constipation  has,  without  doubt,  an  injurious  influence  upon 
the  gcnei'dl  nutrition,  and  many  patients  are  extremely  pallid,  and 
become  emaciated,  depressed,  and  incapable  of"  mental  activity. 
Possibly  these  may  be  consequences  of"  auto-intoxication,  with 
evidences  of  increased  intestinal  putrefaction.  The  disorder  is 
not  dangerous  to  life,  but  is  distressing  and  obstinate. 

Treatment. — The  treatment  is  in  part  general  and  in  part 
local.  The  f/eueral  treatment  should  be  directed  to  the  correction 
of  existing  anemia,  conditions  of  weakness,  and  neuroses.  The 
local  treatment  should  secure  regular  evacuation  of  the  bowels,  and 
the  same  remedies  will  be  required  that  have  already  been 
mentioned  in  the  treatment  of  constipation  in  consequence  of 
chronic  intestinal  catarrh  (pp.  256  and  257). 

NERVOUS  DIARRHEA. 

The  nervous  system  exerts  an  important  influence  upon  in- 
testinal activity,  as  many  persons  are  seized  with  a  desire  for 
stool  and  looseness  of  the  bowels  under  the  influence  of  fear  ami 
embarrassment.  In  hysterical  and  neurasthenic  individuals  diar- 
rhea not  rarely  occurs  for  a  considerable  length  of  time,  and  with 
frequent  relapses,  but  with  an  absence  of  all  signs  of  anatomic 
changes  in  the  bowel.  Tchetic  patients  also  are  at  times  seized 
with  attacks  of  nervous  diarrhea.  It  is  important  to  appreciate 
the  disorder  properly  from  its  etiologic  aspect,  for  the  treatment  of 
the  general  condition  and  the  prescription  of  bromids  are  far  more 
serviceable  than  the  employment  of  styptics.  Xervous  diarrhea 
may  be  due  to  increased  peristaltic  activity  of  the  intestine  alone, 
although  it  is  not  impossible  that  at  times  increased  secretion  of 
intestinal  juice  also  takes  place. 

PERISTALTIC  INTESTINAL  UNREST  (NERVOUS  INTESTINAL  TORMINA^. 

Like  the  stomach  (p.  236),  the  intestine  also  may  be  the  seat  of 
abnormally  excessive  motility,  which  gives  rise  to  a  disagreeable 
feeling  of  rumbling  and  of  unrest,  and  disturbs  sleep  at  night. 
The  causative  factors  and  the  treatment  are  identical  with  those 
of  nervous  unrest  of  the  stomach. 

SENSORY  INTESTINAL  NEUROSES. 

NERVOUS  SPASM   OF  THE  INTESTINE. 

In  hysterical  and  neurasthenic  individuals  spasm  of  the  mus- 
cular layer  of  the  intestine  sometimes  occurs  Mithin  certain  ])or- 
tions  of  the  bowel,  and  gives  rise   to  circumscribed  abdominal 


INTESTINAL  NEUROSES  291 

pain,  and  also  to  constipation.  There  are  thus  two  varieties  of 
constipation  dae  to  intestinal  neuroses,  namely,  the  atonic  and 
the  spastic.  The  peculiar  appearance  of  the  feces  is  considered 
distinctive  of  the  latter.  As  with  stenosis  of  the  bowel,  the  feces 
form  small,  abbreviated  columns  or  they  resemble  coflPee-beans,  or 
the  feces  of  the  sheep  and  the  goat. 

The  treatment  should  be  directed  to  the  cure  of  the  funda- 
mental disorder.  Locally  narcotics  may  be  advised,  especially 
bromids,  opium,  and  belladonna. 

NERVOUS  ENTERALGIA. 

Ktiology. — Intestinal  pain  independent  of  anatomic  alter- 
ations occurs  especially  in  anemic,  hysterical,  and  nervous  individ- 
uals. It  is  well  known  that  in  cases  of  tabes  dorsalis  attacks  of 
severe  intestinal  pain  not  rarely  occur — so-called  intestinal  crises. 
At  times  toxic  influences  are  operative,  as  a  result  of  which  the 
colic  due  to  lead  and  copper  is  best  known.  Gouty  patients  also 
are  not  rarely  seized  with  attacks  of  intestinal  colic.  Some  persons 
suffer  from  intestinal  pain  after  indulgence  in  certain  kinds  of  food, 
without  the  occurrence  of  other  derangement  of  intestinal  activity. 
Intestinal  worms  also  at  times  give  rise  to  intestinal  pain,  as  do 
likewise  fecal  accumulation  and  gaseous  accumulation  in  the  bowel. 
Intestinal  pain  of  reflex  origin  at  times  attends  diseases  of  the 
uterus,  the  kidneys,  and  the  liver.  Attacks  of  intense  pain  are 
sometimes  excited  by  old  peritonitic  adhesions. 

Symptoms  and  Diagnosis. — The  principal  symptom  of 
the  disorder,  which  is  also  known  as  intestinal  colic,  is  abdominal 
pain.  This  is  most  commonly  referred  to  the  umbilical  region, 
but  it  may  radiate  thence  for  a  considerable  distance,  and  at  times 
it  changes  its  position.  Its  severity  is  susceptible  of  great  varia- 
tion, and  fluctuates  between  slight  abdominal  griping  and  cutting 
and  stabbing  pain  of  such  intensity  that  the  patient  writhes  in 
bed,  while  the  skin  becomes  pale  and  cool  (reflex  vascular  spasm), 
cold  sweat  appears,  the  face  presents  an  expression  of  fear,  the 
pulse  is  small  and  hard,  and  the  heart-sounds  faint.  Syncope 
(cerebral  anemia)  and  general  clonic  spasm  may  occur.  At 
times  palpitation  of  the  heart,  a  sense  of  oppression,  contraction 
of  the  cremasteric  muscle,  and  the  like,  may  be  present.  The 
duration  of  an  attack  of  pain  is  susceptible  of  great  variation,  as 
is  also  the  frequency  of  recurrence.  At  times  an  attack  of  colic 
terminates  rather  suddenly,  after  vomiting  or  the  escape  of  gas 
from  the  intestine.  The  abdomen  is  often  scaphoid  and  distended 
and  of  board-like  hardness,  as,  for  instance,  in  the  presence  of 
lead-colic,  although  abdominal  distention  may  also  result  from 
fecal  and  gaseous  accumulation.  As  distinctive,  in  contradis- 
tinction from  intestinal  pain  dependent  upon  anatomic  changes  in 


292  DIGESTIVE  ORGANS 

the  bowel,  it  is  pointed  out  that  strong  pressure  upon  the  abdom- 
inal walls  does  not  increase,  but  usually  mitigates  the  pain,  and, 
as  a  matter  of  fact,  the  patients  not  rarely  press  their  hands  firmly 
upon  the  abdomen  or  apply  the  abdomen  forcibly  against  some 
hard  body. 

Prognosis. — Death  scarcely  ever  occurs  as  the  result  of  an 
attack  of  nervous  intestinal  pain,  and  if  the  fundamental  disorder 
is  curable  the  prospects  are  good  for  the  prevention  of  a  recur- 
rence of  the  attacks  of  jDain. 

Treatment. — Attacks  of  nervous  intestinal  pain  are  most 
speedily  and  most  certainly  relieved  by  a  subcutaneous  injection  of 
morphin  (0.3  :  10 — 4.5  grains  :  2i  fluidrams  ;  from  0.25  to  0.5 — 
(from  4  to  8  minims — subcutaneously),  but  this  should  be  resorted 
to  only  when  the  pain  has  attained  a  marked  degree  of  severity. 
Under  no  conditions  should  the  patient  be  entrusted  with  the 
syringe,  morphin,  and  the  injection,  because  the  danger  of  and 
the  temptation  to  morphinism  are  too  great.  In  less  severe  cases 
the  abdomen  should  be  covered  with  a  hot  cataplasm,  and  hot 
carminative  infusions  mfiy  be  drunk  (peppermint-leaves,  fennel, 
caraway — 1  tablespoonful  to  3  cups  of  hot  water  for  an  infusion). 
Besides,  consideration  should  be  given  to  the  causative  factors — 
causal  therapy — which  coincides  with  the  lyropliylaxis. 


ANIMAL   PARASITES   OF    THE    INTESTINE    (INTES- 
TINAL HELMINTHIASIS). 

PROTOZOA  IN  THE  INTESTINE. 

Protozoa  in  the  intestine  have  been  frequently  discovered  acci- 
dentally on  microscopic  examination  of  the  stools.  They  liave 
been  found  especially  in  cases  of  chronic  diarrhea,  so  that  it  is 
assumed  not  without  reason  that  they  are  capable  of  inducing  or 
maintaining  chronic  diarrhea.  Many  physicians  consider  these 
parasites  as  harmless  bodies.  Earnest  consideration  has  been 
given  in  recent  years  to  the  presence  of  amebse  in  cases  of  tropical 
endemic  dysentery,  so  that  the  designation  amebic  dysentery  has 
been  employed. 

Stools  intended  for  examination  for  the  presence  of  protozoa  should  be 
fresh,  for  on  standing  the  protozoa  are  transformed  into  roundish,  immo- 
bile structures,  -which  cannot  be  distinguished  from  the  colorless  blood- 
corpuscles.  It  is  advisable  to  obtain  the  fecal  matter  directly  from  the 
rectum  by  means  of  blunt-edged  glass  tubes. 

Among  the  better  known  protozoa  are  the  following: 

1.  Amceba  coU. — This  is  a  rhizopod,  and  appears  in  the  form  of  round- 
ish granular  bodies,  with  a  nucleus  and  a  nucleolus,  which  engage  in  move- 
ment by  the  extension  and  retraction  of  pseudopods  (p.  293,  Fig.  28).  A 
distinction  has  further  been  made  between  Amceba  coli,  Amoeba  coli  mitis, 
Amoeba  intestinalis  vulgaris,  and  Amoeba  coli  felis. 


ANIMAL  PARASITES  OF  THE  INTESTINE  293 

2.  Cercomonas  intestinalis  (p.  294,  Fig.  29)  is  a  pear-shaped  body,  which 
possesses  a  long  vibratile  flagellum  at  its  anterior  extremity,  and  a  caudal 
process  posteriorly,  which  serves  as  a  means  of  attachment.  This  body, 
like  all  of  the  following  protozoa  of  the  intestine,  belongs  to  the  Infusoria. 

3.  Cercomonas  coli  is  provided  with  four  vibratile  flagella  arising  from 
the  anterior  portion  of  the  body.  A  lateral  border  undulates  (p.  294,  Fig. 
30). 

4.  Trichomonas  intestinalis. — This  parasite  resembles  an  almond-kernel 
in  shape.  Cilia  are  present  upon  one  side,  while  posteriorly  there  is  a 
pointed  process  for  purposes  of  attachment  (p.  294,  Fig.  31). 

5.  Megastomum  entericum. — This  parasite  has  been  compared  with  the 
half  of  a  pear.  Anteriorly  it  is  provided  with  six  flagella,  which  in  the 
dead  parasite  have  disappeared  (p.  294,  Fig.  32). 

6.  Balantidium  s.  Paramoeciwn  coli. — This  parasite  is  egg-shaped  and  is 
surrounded  by  cilia.  Anteriorly  an  oral  orifice  and  posteriorly  an  anal  orifice 
can  be  recognized.  The  interior  of  the  body  contains  vacuoles  and  particles 
of  food  (p.  294,  Fig.  33). 

It  is  well  in  all  cases  to  cause  the  expulsion  of  protozoa  from 
the  intestine  even  when  morbid  manifestations  are  not  present. 
Intestinal  infusions  of  quinin  (1.0  :  1000),  of  mercuric  chlorid 
(0.3  :  1000),  or  of  a  solution  of  tannic  acid  (0.5  per  cent.)  are  espe- 
cially to  be  recommended. 

WORMS  IN  THE  INTESTINE. 

FLAT  WORMS  (PLATYHELMINTHES). 

TAPEWORMS   (CESTODES). 

il^tiology. — Among  the  various  kinds  of  tapeworm  three  are 
of  practical  significance  on  account  of  their  frequent  and  wide- 
spread occurrence,  namely,  the  unarmed  tapeworm,  Taenia  medio- 
canellata  s.  saginata,  the  armed  tapeworm,  Taenia  solium,  and  the 
Bothrioeephalus  latus.  Tapeworms  are  acquired  only  by  the  in- 
gestion of  measly  meat.  In  the  stomach  the  capsule  of  the  measle 
is  digested,  and  its  head  or  rather  that  of  the  tapeworm  (scolex) 
is  set  free,  and  then  develops  within  the  intestine  by  the  forma- 
tion of  segments  or  proglottides  into  the  mature  parasite.  From 
time  to  time  the  more  distal  (the  oldest)  segments  are  expelled. 
Animals  that  eat  feces  contaminated  with  proglottides  digest  the 
segments.  In  this  way  the  contained  ova  are  set  free,  and  migrate 
from  the  intestine  into  the  muscles,  where  they  again  develop  into 
measles.  The  Tcenia  saginata  is  acquired  from  the  measle  of  beef, 
the  Tcenia  .solium  from  that  of  swine,  the  Cysticereus  cellulosce  and 
the  Botliriocephahis  latus  from  that  of  fish.  As  the  use  of  beef  is 
customary  in  all  parts  of  the  world,  it  may  be  readily  understood 
that  the  Taenia  saginata  occurs  most  commonly  and  in  all  countries. 
The  use  of  pork  is  avoided  by  many  on  account  of  its  fat,  and  is 
forbidden  Jews  and  Orientals  on  religious  grounds,  so  that  the 
Taenia  solium  is  much  less  common.  The  occurrence  of  Bothrio- 
eephalus latus  is  confined  to  certain  situations  on  the  coast  and  on 


294 


DIGESTIVE  ORGANS 


inland  seas,  among  which  may  be  mentioned  the  Russian  provinces 
on  the  Baltic  Sea,  the  coast  of  Eastern  Prussia  and  Pomerania, 


Fig.  29.— Cercomonas  intestinalis  (after  Lambl). 


Fig.  28. — Amceba  coli  (after  Losch). 


Fig.  30. — Cercomonas  coli  (after  Jlay). 


and  the  banks  of  the  Lake  of  Geneva.     Various  fish  may  contain 
measles,  such  as  salmon,  eel-pout,  pike,  salmon-trout. 


Fig.  31. — Trichomonas  intestinalis  (after  Zenker). 


Fig.  32. — Megastomum  entericum  : 
a,  in  the  fresh,  b,  in  the  dead  state 
(after  Bizzozero  and  Grassi). 


Tapeworms  occur  in  different  countries  with  varying  frequency. 

In  tlie  Orient  persons  free  from  tapeworms  are  almost  the  excep- 
tion. This  may  be  explained  in  part  by  local 
customs — as,  for  instance,  the  use  of  raw  meat 
favors  the  prevalence  of  tapeworm,  as  the 
measles  are  generally  destroyed  and  rendered 
harmless  by  cooking ;  and  in  part  by  want  of 
cleanliness  in  the  stables,  and  carelessness  in 
the  inspection  and  sale  of  meat.  If  domestic 
animals  are  not  restrained  from  eating  human 
fecal  matter,  if  the  sale  of  measly  meat  is  not 
prohibited,  if  measly  meat  is  sold  in  butcher- 
shops  together  with   healthy   meat,  and   if  all 

meat  is  carved  with   the  same  knife,  all  of  these  conditions  are 

factors  that   favor  the   infection   of  animals   and   human  beings. 

Tapeworms  occur  with  greatest  frequency  in  adults.     They  have 


Fig.  33.— Balantidium  s. 
paramoecium  coli. 


ANIMAL  PARASITES  OF  THE  INTESTINE 


295 


been  variously  observed  in  children  when  raw  shaved  beef  has 
been  recommended  in  the  presence  of  diarrhea. 

Symptoms,  Diagnosis,  and  Anatomic  Alterations. — 

The  presence  of  a  tapeworm  in  the  intestine  can  be  recognized 
with  certainty  only  when  proglottides  or  ova  or  tlie  entire  worm 
is  voided  with  the  stool.  Proglottides  or  segments  can  be  readily 
recognized,  and  may  be  properly  compared  wdth  the  appearance 
of  flat  noodles.  Only  on  superficial  examination  would  confusion 
with  undigested  elastic  tissue  or  with  the  fibrous  remains  of  aspar- 
agus be  possible.  Proglottides  are  passed  singly  from  time  to 
time,  or  in  case  of  the  Bothriocephalus  latus  in  groups  of  several 
in  the  form  of  small  chains,  and  facilitate  a  diagnosis  as  to  the 
variety  of  tapeworm.  In  the  fresh  state  they  exhibit  movement, 
inversion,  and  the  like.  Proglottides  of  the  Taenia  saginata  are 
greater  in  length  than  in  width,  and  exhibit  upon  one  side  at  about 
the  middle  a  knob-like  process — the  entrance  to  the  genital  canal — 
and  in  addition  numerous  ramifications  (from  15  to  20)  of  the 
uterus.  The  latter  can  be  seen  with  particular  distinctness  if  a 
proglottis  is  compressed  between  two  slides.  The  proglottides  of 
the  Taenia  solium  resemble  entirely  those  of  the  Taenia  saginata, 
with  the  exception  that  the  divisions  of  the  uterus  are  thicker  and 
less  numerous  (from  5  to  12).  The  proglottides  of  the  Bothrio- 
cephalus latus  present  an   entirely  different  appt^arance.     In  the 


Tapeworm-proglottides  ;  natural  size  (from  personal  preparations) 
Fig.  34.— Of  Taenia  saginata.      Fig.  35.— Of  Taenia  solium. 


Fig.  36.— Of  Bothriocepha- 
lus latus. 


first  place,  their  width  is  greater  than  their  length,  and,  besides, 
the  uterus  is  arranged  in  the  shape  of  a  roset  in  the  middle  (Figs. 
34,  35,  36). 

The  ova  of  tapeworms  are  too  small  to  be  seen  with  the  unaided 


Tapeworm-ova;  magnified  370  times  (from  original  preparations). 

Fig.  37.— Of  Ta;nia  Fig.  38.— Of  Taenia       Fig.  39.— Of  Bothriocephalus    latus. 

saginata.  solium. 


eye.  They  are  at  times  discovered  accidentally  on  microscopic 
examination  of  the  stools.  The  differentiation  between  the  ova 
of  bothriocephalus  and  those  of  the  tsenise  is  easy.     The  eggs  of 


296  DIGESTIVE  ORGANS 

bothrioccphalus  are  oval,  present  at  one  extremity  a  cover,  and  are 
filled  with  a  number  of  spherules.  The  ova  of  taeniae,  on  the  other 
hand,  possess  a  striated  shell,  i2:ranular  contents,  and  six  booklets 
in  the  latter.  The  differentiation  between  the  ova  of  Taenia  sagi- 
nata  and  those  of  Ta?nia  solium  is  difficult,  as  they  resemble  each 
other,  and  differ  only  in  size,  those  of  Taenia  solium  being  smaller 
(0.032  and  0.036  m'm.)  than  those  of  Taenia  saginata  (0.035  and 
0.039  mm.)  (Figs.  37,  38,  39). 

It  is  rare  for  tapeworms  to  be  expelled  entire  with  the  stools. 
This  has  been  observed  in  febrile  patients,  in  cases  of  diarrhea, 
and  during  courses  of  treatment  at  the  springs.  In  rare  instances 
tapeworms  pass  from  the  intestine  into  the  stomach,  are  in  part 
vomited,  and  must  be  extracted  with  the  fingers. 

The  recognition  of  the  variety  of  tapeworm  naturally  can  be  readily 
made  from  the  appearance  of  the  individual  segments.  These  become 
shorter,  smaller,  and  thinner  as  they  approach  the  head,  and  the  neck  is 
almost  filamentous.  The  head  barely  attains  the  size  of  a  pin-head  (p.  297, 
Figs.  40,  41).  In  the  Bothriocephalus  latus  it  has  a  flat  and  club-shaped 
appearance,  in  the  Taenia  saginata  and  the  Taenia  solium  a  roundish  form. 
If  the  head  be  examined  with  high  powers  of  the  microscope,  four  suckers 
are  observed  ;  in  the  Ttenia  saginata,  and  in  the  Taenia  solium  in  addition  to 
four  booklets  also  an  anterior  prominence  or  rostellum,  which  is  sur- 
rounded by  from  26  to  30  booklets,  and  finally  in  the  bothriocephalus  two 
longitudinal  deep  grooves  like  suckers  (p.  299,  Figs.  42,  43,  44).  It  may  be 
incidentally  mentioned  that  of  all  tapeworms  the  Taenia  saginata  attains 
the  greatest  length  (up  to  8  meters).  It  may  consist  of  as  many  as  1300  seg- 
ments, of  which  about  the  six  hundredth  belaind  the  cervical  portion  begins 
to  be  mature  sexually.  The  Taenia  solium  attains  a  length  of  3^  meters,  and 
is  constituted  of  as  many  as  850  segments.  The  Bothriocephalus  latus 
measures  from  5  to  8  meters  in  length,  and  is  composed  of  as  many  as  4000 
segments.  Tapeworms  are  found  in  the  small  intestine,  to  the  mucous  mem- 
brane of  which  they  adhere  by  means  of  their  suckers,  while  the  remainder 
of  the  body  is  directed  with  numerous  convolutions  toward  the  anus.  In 
the  majority  of  instances  but  a  single  tapeworm  is  present  in  the  bowel. 
Should  several  be  present,  they  are  generally  of  the  same  variety.  In  rare 
instances  a  number  of  tapewoi'm-heads  have  been  observed  in  an  entangled 
convolution,  with  their  adjacent  cervical  portions.  Injuries  of  the  intes- 
tinal mucous  membrane  are  not  induced  by  the  application  of  the  suckers 
of  the  head  of  the  tapeworm. 

Persons  harboring  tapeworms  are  often  wholly  free  from  sub- 
jective symptoms,  and  become  cognizant  of  the  presence  of  the 
parasite  accidentally  through  the  discovery  of  the  proglottides  in 
the  stools.  In  others  a  train  of  symptoms  develops  ;  but  these  are 
unreliable,  and  in  some  instances  only  a  result  of  the  fear  of  tape- 
worm. Among  suspicious  symptoms  there  have  been  mentioned 
irregularity  in  the  action  of  the  bowels,  with  at  times  extremely 
constipated,  at  other  times  loose  stools,  colic,  borborygmi,  a  sense 
of  distortion  and  twisting  in  the  bowel,  excessive  secretion  of 
saliva,  a  disagreeable  odor  from  the  mouth,  eructation,  vomiting, 
insatiable  hunger,  but  also  anorexia,  emaciation,  and  pallor. 
Earlier  physicians  reported  the  occurrence  of  serious  nervous  dis- 


ANIMAL  PARASITES  OF  THE  INTESTINE 


297 


turbances,  such  as  eclampsia  and  chorea.  Vertigo  is  not  rarely 
complained  of.  Inequality  of  the  pupils  is  often  present.  The 
occurrence  of  Charcot-Neumann  crystals 
in  the  stools  in  abundance  is  suspicious 
(p.  115,  Fig.  20).  Recently  attention  has 
been  directed  to  profound  anemic  states 
in  persons  harboring  Bothriocephalus 
latus.     This  bothriocephalus-anemia  in  its 


m 


im 


Tapeworms,  natural  size.    (From  personal  preparations). 
Fig.  40.— Taenia  saginata.  Fig.  41.— Bothriocephalus  latus. 


298  DIGESTIVE  ORGANS 

symptomatology  completely  resembles  pernicious  anemia,  except 
tiiiit  retinal  hemorrhages  and  febrile  movement  are  less  e<jmmon 
witli  the  former.  After  expulsion  of  the  Ijothriocephalus  the 
patients  often  recover  with  remarkable  rapidity.  It  is  assumed 
that  hemogenesis  is  interfered  with  through  the  action  of  toxic 
substances  (ptomains)  generated  by  the  tapeworm,  and  which 
develop  especially  when  the  parasite  has  died  within  the  intes- 
tinal canal.  In  cases  in  which  the  diagnosis  of  tapeworm  is  doubt- 
ful a  small  amount  of  extract  of  male  fern  should  be  administered 
and  the  stools  be  examined  for  proglottides  and  ova  : 

B  Extract  of  filix  mas, 

Rhizome  of  filix  mas,  each,  2.0  (30  grains). — M. 

Make  20  pills. 
Dose :  Take  10  pills  morning  and  evening. 

Prognosis. — Tapeworms  give  rise  to  an  unpleasant  but  not 
to  a  dangerous  disease.  Only  rarely  does  the  host  of  a  tapeworm 
infect  himself  with  the  eggs  of  proglottides,  M'ith  the  develop- 
ment of  measles  in  other  organs,  as,  for  instance,  in  the  subcu- 
taneous connective  tissue,  the  eye,  the  muscles,  or  the  brain. 
Caution  should  be  observed  in  promising  success  in  the  treatment 
of  tapeworm,  for  not  rarely  the  usual  remedies  prove  unsuccessful, 
and  must  be  repeated.  The  failure  appears,  provided  efficient 
medicaments  are  employed,  to  depend  often  upon  the  fact  that  the 
head  of  the  worm  is  concealed  behind  a  fold  of  intestinal  mucous 
membrane,  and  consequently  is  inaccessible  to  the  action  of  the 
drug. 

Treatment. — The  treatment  of  tapeworm  consists  in  three 
parts,  namely,  the  preparatory  treatment  and  the  narcotization,  or 
destruction,  and  expulsion  of  the  worm.  All  varieties  of  treatment 
demand  a  certain  degree  of  bodily  vigor,  and  they  should  not  be 
undertaken  in  convalescents,  sufferers  from  pulmouarv  tuliercu- 
losis  and  from  carcinoma,  pregnant  women,  and  those  otherwise 
debilitated.  During  the  period  that  the  teniacide  is  administered 
the  patient  should  remain  in  bed,  as  otherwise  vomiting,  vertigo, 
and  syncope  may  readily  take  place.  The  object  of  the  prepara- 
tory treatment  is  to  empty  the  intestine  as  thoroughly  as  ])0ssible, 
in  order  that  the  specific  tapeworm-remedy  may  the  better  gain 
access  to  the  parasite,  and  besides  to  render  conditions  unfavoralile 
for  the  persistence  of  the  worm  in  the  intestine.  NVith  this  object 
in  view,  a  mild  laxative  is  given  for  one  or  two  days,  as,  for 
instance,  a  teaspoonful  of  licorice-powder  in  water  in  the  morning, 
while  fruit  with  small  seeds  (strawberries,  raspberries,  gooseber- 
ries, currants)  should  be  eaten,  and  considerable  milk,  eggs,  and 
meat,  but  little  bread,  potatoes,  and  vegetables,  be  taken.  On  the 
night  before  the  teniacide  is  aduiinistered  the  patient  should  take 
a  salad  constituted  of  dried  herring,  garlic,  and  onions.  The  object 
of  the  teniacide  is  to  narcotize  the  tapeworm  so  that  it  relaxes 


ANIMAL  PARASITES  OF  THE  INTESTINE 


299 


'  the  grasp  of  its  suckers  upon  the  intestinal  mucous  membrane, 
and  can  be  mechanically  expelled  with  the  intestinal  c(jntents. 
The  most  reliable  teniacide  is  freshly  prepared  extract  of  filix  mas 
given  in  sufficient  dose.     We  have  of  late  employed  with  satis- 


FiG.  42.— Head  of  Taenia  solium. 


Tapeworm  heads  ;  magnified  60  times.    (From  personal  preparations.) 
Fig.  43.— Head  of  Taenia  saginata.  Fig.  44.— Head  of  Bothriocephalus  latus. 

factory  results  an  extract  of  filix  mas  enclosed  in  gelatin-capsules. 
Gelatin-capsules  containing  castor-oil  may  also  be  given  for  the 
mechanical  expulsion  of  the  worm.  Filix  mas  may  further  be 
prescribed  in  the  following  manner : 


300  DIGESTIVE  ORGANS 

R  Extract  of  filix  mas,  10.0  (2 J  drams); 

Powdered  althea,  suflBcient  to  make  30  pills. 
Dose:  In  the  morning  at  7  and  7.30,  when  the  stomach 
is  empty,  15  pills. 

A  tendency  to  vomit  may  be  counteracted  by  swallowing  black 
coffee  or  lemonade. 

The  number  of  tapeworm-remedies  is  verj'  large,  and  of  these  may  be 
mentioned  kousso- flowers  (25.0 — %  ounce — to  be  taken  in  two  parts  in  the 
morning  in  water) ;  koussin  (3.0 — 45  grains — to  be  taken  in  the  morning  in 
two  parts) ;  kamala  (15.0 — ^  ounce — to  be  taken  in  the  morning  in  two 
parts  in  water) ;  cortex  of  pomegranate-root  (50.0  :  300 — 1 J  ounces  :  10  fluid- 
ounces — in  the  morning  in  two  parts)  ;  pelletierin  (0.3 — 4^  grains — in  two 
parts) ;  zinc-filings  in  sirup ;  and  pumpkin-seed. 

It  is  advisable  to  follow  the  administration  of  the  teniacide 
after  an  interval  of  two  hours  by  the  expulsive  treatment,  unless 
the  bowels  have  been  moved  before  this  time,  and  the  tapeworm 
at  the  same  time  expelled  ;  otherwise  the  tapeworm  might  recover, 
apply  itself  anew  to  the  intestinal  mucous  membrane,  and  neutral- 
ize the  success  of  the  treatment.  The  simplest  prescription  con- 
sists of  castor-oil  (50.0 — 1^  fluidounces)  in  black  coffee.  Intestinal 
infusions  of  decoctions  of  the  rhizome  of  filix  mas  (5.0  :  500 — 
75  grains  :  15  fluidounces)  may  also  be  advised.  Frequently  the 
tapeworm  is  not  expelled  entire,  but  in  several  parts ;  or  it  may 
happen  that  a  portion  is  expelled  while  the  remainder  is  retained 
within  the  rectum  and  protrudes  from  the  anus.  In  the  latter 
event  it  is  important  not  to  exert  traction  upon  the  protruding 
portion,  as  the  worm  may  readily  tear  at  the  neck ;  and  if  this, 
with  the  head,  remain  within  the  bowel,  it  may  again  attach  itself 
to  the  mucous  membrane  and  attain  its  former  size.  After  treat- 
ment for  tapeworm  all  parts  of  the  parasite  passed  should  be 
collected  and  be  carefully  examined  for  the  head.  Should  this 
not  be  found,  the  treatment  cannot  be  looked  upon  as  successful. 
The  tapeworm  will  have  acquired  its  previous  size  in  the  course 
of  six  months  on  an  average,  and  will  reveal  its  presence  in  the 
bowel  by  the  reappearance  of  mature  proglottides  in  the  stools. 
The  treatment  must  then  be  repeated.  Some  patients  are  freed 
from  the  parasite  only  after  several  repetitions  of  the  treatment. 

Attention  should  be  given  to  the  prophylactic  measures  ag-ainst 
the  s]:)read  of  tapeworm.  These  will  suggest  themselves  from  a 
consideration  of  the  causative  factors,  and  consist  especially  in  the 
official  inspection  of  meat  and  prohiliition  of  the  sale  of  all  that 
is  measled,  in  the  avoidance  of  raw  or  insufficiently  cooked  meat, 
in  cleanliness  of  the  stables  and  preventing  the  animals  from 
ingesting  fecal  matter.  If  the  sale  of  measly  meat  is  permitted, 
this  should  be  sold  separately,  from  a  distinct  table,  and  be  indicated 
as  such.  The  purchaser  should  be  instructed  to  cook  the  meat 
thoroughly.    Those  engaged  in  slaughtering  should  employ  special 


ANIMAL  PARASITES  OF  THE  INTESTINE 


301 


knives  for  measly  meat,  so  as  to  avoid  the  conveyance  of  measles 
to  healthy  meat. 

SUCKING   WORMS   (tREMATODES). 

Sucking  worms  (Distoma  crassum,  Distoma  heterophyes,  Dis- 
toma  haematobium)  have  been  found  in  the  intestine  only  in 
isolated  instances,  and  have  given  rise  to  ulcerative  changes. 

ROUND   WORMS   (NEMATHELIMINTHES). 
SPOOL-WORM    (aSCARIS    LUMBRICOIDES). 

Symptoms,  Anatomic  Alterations,  Diagnosis,  and 
Prognosis. — The  spool-worm  in  appearance  and  size  resembles 
the  earth-worm.  The  males  are  smaller  than  the  females,  and  at 
the  posterior  extremity  of  the  body  exhibit  an  inversion  toward 
the  ventral  aspect.  If  spool-worms  are  passed  with  the  stools, 
they  can  be  readily  recognized.  The  diagnosis  can  also  be  made 
with  certainty  if  the  ova  of  spool-worms  can  be  demonstrated  in 
the  stools.  These  are  frequently  present  in  small  portions  of  fecal 
matter  that  remain  adherent  to  the  anal  region.     On  microscopic 


Fig.  45. — Ova  of  Ascaris  lumbricoides ;  magnified  275  times  (personal  observation,  Zurich 

clinic). 

examination  the  egg  is  found  to  consist  of  a  granular  body,  which 
is  surrounded  by  a  thick,  bright,  wavy,  and  nodular  shell  (Fig.  45). 
The  subjective  symptoms  are  never  so  distinctive  as  to  render 
possible  a  certain  diagnosis.  The  symptoms  are  in  part  local,  in 
part  reflex  (nervous)  in  nature.  Of  late  it  has  been  properly 
emphasized  that  toxic  influences  may  also  be  operative,  because 
examination  of  spool-worms  has  in  several  instances  disclosed  the 
presence  of  toxic  activity  (inflammation  of  the  eye,  irritation  of 
the  skin).     The  local  disturbances  include  abdominal  pain,  bor- 


302  DIGESTIVE  ORGANS 

borygmi,  irregularity  of  bowel-movement,  itching  at  the  anus, 
anorexia,  nausea,  vomiting,  and  offensive  odor  of  the  breath.  The 
reflex  disturbances  include  especially  certain  nervous  manifesta- 
tions, such  as  vertigo,  headache,  inequality  of  the  pupils,  eclampsia, 
paralysis,  chorea,  muscular  spasm,  and  the  like.  The  patient  often 
complains  of  distressing  itching  in  the  nose,  and  frequently  digs 
the  lingers  in  the  nares.  He  often  attracts  attention  on  account  of 
his  pallid  appearance,  the  presence  of  deep  rings  around  the  eyes, 
and  progressive  emaciation.  Spool-worms  are  not  rarely  found  in 
the  dead  body,  and  one  can  convince  himself  that  they  lodge  in 
the  small  intestine.  At  times  they  occur  in  such  great  number 
that  they  occupy  the  entire  lumen  of  the  bowel.  It  is  recorded 
that  in  one  case  several  thousand  parasites  were  expelled  with  the 
stools. 

Injury  is  not  inflicted  upon  the  healthy  intestinal  wall  from 
the  presence  of  spool-worms,  and  but  rarely  do  they  become  so 
entangled  as  to  cause  symptoms  of  obstruction  of  the  bowel.  In 
general,  spool-worms  are  harmless  intestinal  parasites.  Danger 
arises  only  from  their  migratory  tendency.  Spool-worms  exhibit  a 
tendency  especially  to  penetrate  through  narrow  orifices.  Their 
entrance  into  the  choledoch  duct  and  their  migration  upward  may 
readily  give  rise  to  obstructive  jaundice,  which  is  usually  incurable, 
and  at  times  also  to  abscess  of  the  liver.  Spool-worms  have  also 
been  found  forming  the  nuclei  of  gall-stones.  iSTot  rarely  they 
invade  the  stomach,  where  they  occasion  a  sense  of  pressure  and 
of  pain,  and  are  finally  ejected  by  vomiting,  when  the  pain  at  once 
ceases.  At  times,  however,  they  wander  through  the  stomach  and 
the  esophagus  during  the  night  into  the  larynx,  lodging  above  the 
vocal  bands,  and  causing  death  by  suffocation  during  sleep.  If 
they  advance  beyond  the  chink  of  the  glottis,  they  may  enter  deep 
into  the  bronchial  tubes  and  excite  abscess  and  gangrene  of  the 
lung.  At  times,  also,  they  enter  the  nose,  the  lacrimal  duct,  the 
internal  ear  througli  the  Eustachian  tube,  and,  on  perforation  of  the 
tympanic  membrane,  even  the  external  auditory  canal,  and  tliey 
must  then  be  removed  with  the  fingers  from  the  nose,  the  lacrimal 
caruncles,  or  tlie  external  auditory  canal.  In  cases  of  perforative 
peritonitis  spool-worms  are  not  rarely  found  free  in  the  abdominal 
cavity  and  in  tlie  peritoneal  exudate.  As  a  rule,  the  worms  wander 
into  the  peritoneal  cavity  through  the  opening  in  the  bowel  after 
the  perfi)ration  has  taken  place.  It  should,  however,  not  be  con- 
sidered impossible  that  in  some  cases  tlie  parasites,  with  their  hard 
cephalic  extremities,  may  cause  perforation  of  an  ulcerative  process 
in  the  bowel.  Not  rarely  repeated  infection  witli  sjiool-worms 
occurs  if  exposure  is  rejieated. 

Ktiologfy. — Only  those  are  infected  by  spool-worms  who 
swallow  the  ova  of  the  parasites.  Such  ova  have  been  demon- 
strated in  water,  obviously  from  contamination  with  fecal  matter. 


ANIMAL  PARASITES  OF  THE  INTESTINE 


303 


Transmission  probably  takes  place  most  commonly  through  vege- 
tables, which  become  infected  with  the  ova  of  spool-worms  in  the 
process  of  manuring  (cattle  and  pigs  often  harbor  spool-worms)  and 
are  not  sufficiently  washed  before  being  used.  Infection  may  also 
occur  from  swallowing  with  the  food  minute  particles  of  fecal 
matter  that  have  adhered  to  the  fingers.  The  greater  the  want  of 
cleanliness  in  a  household,  and  the  less  the  care  exercised  by  its 
individual  members,  the  greater  is  the  danger  of  transmission. 
This  fact  explains  the  greater  frequency  of  spool-worms  in 
Oriental  people,  in  the  insane,  and  in  children. 

Treatment. — Spool-worms  may  be  narcotized  and  expelled 
with  "greatest  certainty  by  means  of  santonin,  a  remedy  obtained 
from  the  flowers  of  Artemisia  maritima  : 

R  Santonin-troches,  No.  10. 
Dose :  1  troche  thrice  daily. 

The  troches  officinal  in  Germany  contain  0.025  (^  grain)  of  santonin, 
but  this  dose  may  give  rise  to  toxic  manifestations  (yellow  vision,  yellowish 
discoloration  of  the  skin,  the  sclera,  and  the  urine,  delirium,  convulsions). 

The  prophylaxis  consists  in  domestic  and  personal  cleanliness. 

In  isolated  instances  the  spool-worm  of  the  cat — Ascaris  mystax — has  been 
observed  in  human  beings.  It  is  smaller  than  the  Ascaris  lumbricoides,  and 
is  characterized  by  the  presence  of  a  wing-shaped  process  at  its  cephalic 
extremity.     In  Greenland  the  Ascaris  maritima  further  occurs. 

SEAT-WORM     (OXYURIS    VERMICULARIS). 

Symptoms,  Diagnosis,  Anatomic  Alterations,  and 
Prognosis. — The  diagnosis  of  seat-worms  is  possible  only  when 
the  parasites  themselves  or  their  ova  are  present  in  the  stool. 
The  worms  are  small  bodies  resembling  the  maggots  of  cheese, 
and  presenting  a  delicate  filamentous  caudal    extremity.      The 


Fig.  46.— Seat-worm  (Oxyuris 
vermicularis) ;  natural  size  :  Fe- 
male on  the  left,  male  on  the  right. 
(From  personal  preparations.) 


Fig.  47.— Ova  of  Oxyuris  vermicularis ;  magnified 
275  times.    (From  personal  preparations.) 


males,  which  are  scarcely  half  as  long  as  the  females,  are  incur- 
vated  at  their  posterior  extremity  (Fig.  46).  The  eggs  are  oval, 
and  possess  granular  contents  and  a  bright  shell  (Fig.  47).  The 
ova  can  frequently  be  obtained  from  remnants  of  fecal  matter  at 


304  DIGESTIVE  ORGANS 

the  anus.  Not  rarely  seat-worms  are  present  in  the  stools  in  such 
great  number  tliat  the  fecal  matter  presents  the  appearance  of  a 
living,  swarming  mass.  Patients  complain  in  part  of  local  and 
in  part  of  reflex  nervous  disturbances. 

The  local  disturbances  include  abdominal  pain,  rumbling,  irreg- 
ularity in  the  movement  of  the  bowels,  intolerable  itching  at  the 
anus,  anorexia,  offensiveness  of  the  breath,  nausea,  and  vomiting. 
The  nervous  symptoms  consist  in  headache,  vertigo,  inequality  of 
the  pupils,  eclampsia,  chorea,  paralysis,  itching  of  the  nose,  and 
the  like.  The  patients  often  attract  attention  by  their  pallor,  and 
their  deep  and  ringed  eyes.  Seat-worms  are  found  principally  in 
the  lowermost  portions  of  the  small  intestine,  and  only  after  fer- 
tilization has  taken  place  do  the  impregnated  females  migrate  into 
the  large  intestine,  where  they  may  be  present  in  such  large  num- 
ber that  the  mucous  membrane  acquires  a  rough  aud  felt-like 
appearance.  Not  rarely  a  number  of  worms  may  escape  from  the 
rectum  during  the  night,  and  are  found  upon  the  sheets  when  the 
bed  is  prepared  in  the  morning.  At  times,  however,  they  crawl 
over  the  perineum  into  the  vagina,  or  beneath  the  prepuce,  and 
give  rise  to  mucopurulent  discharges  and  secretion.  The  intoler- 
able itching  may  cause  onanism  in  children.  Seat-worms,  while 
not  dangerous,  may  constitute  a  most  obstinate  disorder,  so  that 
not  rarely  repeated  and  thorough  courses  of  treatment  may  be  re- 
quired before  a  perfect  cure  is  effected.  In  the  absence  of  a 
proper  degree  of  cleanliness  repeated  infection  may  take  place. 

Ktiology. — Seat-worms  are  acquired  by  the  swallowing  of 
ova.  Auto-infection  may  readily  take  place  if  small  amounts  of 
fecal  matter  containing  the  ova  remain  adherent  to  the  fingers,  and 
are  swallowed  unconsciously  with  the  food.  Children,  women, 
and  the  insane  are  the  most  common  hosts  of  seat-worms.  Often 
infection  takes  place  between  sisters  and  brothers,  bed-fellows, 
and  domestic  servants. 

Treatment. — Efforts  should  be  made  to  narcotize  seat-worms 
bv  means  of  troches  of  santonin  (1  troche  thrice  daily),  and  be- 
sides to  remove  them  mechanically  from  the  intestine  by  means  of 
injections  into  the  bowel.  A  decoction  of  finely  divided  garlic 
with  water,  which  has  stood  for  twelve  hours,  and  is  then  strained 
through  linen,  may  be  usefully  employed  for  injection.  The  infu- 
sions should  be  repeated  for  several  days  successively.  To  pre- 
vent migration  of  the  intestinal  parasites  over  the  perineum,  this 
should  be  anointed  in  the  evening  witli  mercurial  ointment. 

WHIP-A\ORM  (tRIOHOCEPHALUS   DISPAE). 

The  whip-worm  is  of  no  clinical  interest,  and  is  usually  found 
in  the  stools  accidentally.  It  lodges  in  the  cecum,  and  is  charac- 
terized by  a  thin  cephalic  and  a  thick  caudal  extremity,  so  that  it 


ANIMAL  PARASITES  OF  THE  INTESTINE  305 

suggests  the  appearance  of  a  whip.  The  male  is  smaller  than 
the  female,  and  its  thicker  caudal  extremity  is  rolled  up  toward 
the  dorsal  aspect  (Fig.  48).  The  eggs  of  the  parasite  are  oval 
granular  bodies,  with  a  bright  sheath,  presenting  knob-like 
swellings   at   either   pole   (Fig.  49).      Infection    probably  takes 


Fig.    48.— Whip  -  worm  Fig.  49.— Ova  of  whip-worm  (Trichocephalus  dispar) ; 

(Trichocephalus    dispar)  ;  maguifled  275  times  (from  personal  preparations), 

male  to  the  right,  female 
to  the  left;  natural  size 
(from  personal  prepara- 
tions). 

place  through  the  ingestion  of  ova  with  insufficiently  cleansed 
vegetables.  In  the  case  of  a  child  it  took  place  through  the  eat- 
ing of  garden-earth,  in  which  the  ova  of  trichocephalus  were 
demonstrated.^ 

TRICHINA    SPIRALIS.^ 

Htiology. — As  a  rule,  human  beings  are  attacked  by  trichini- 
asis  (trichinosis)  in  consequence  of  the  ingestion  of  pork  or  ham 
containing  trichinae.  Only  exceptionally  does  infection  take  place 
through  other  animals,  as,  for  instance,  the  wild  boar.  If  trich- 
inous  meat  is  eaten,  muscle-fibers  and  trichina-capsules  are  dis- 
solved in  the  process  of  gastric  digestion,  and  the  muscle-trichinae 
of  the  meat  are  set  free.  These  enter  the  small  intestine,  develop 
within  two  and  a  half  days  into  intestinal  triehince,  engage  into 
sexual  relations,  and  in  the  course  of  a  week  the  females  reproduce 
numerous  young.  While  the  parent  ova  die  in  the  course  of  from 
five  to  eight  weeks,  and  are  expelled  from  the  intestine  with  the 
stools,  the  young  brood  wanders  from  the  intestine,  and  the  para- 
sites find  their  way  into  the  muscles.  Here  they  penetrate  the 
muscle-fibers  and  are  subsequently  surrounded  by  a  capsule.  They 
have  thus  become  musde-trichince  in  the  human  being.  Trichini- 
asis  includes  the  period  of  time  included  between  the  ingestion  of 
trichinous  meat  and  the  final  transformation  of  the  brood  of 
trichinae  into  the  muscle-trichinae  in  the  human  being. 

1  Several  cases  of  extreme  anemia  due  to  the  Trichocephalus  dispar  have  been 
reported. — A.  A.  E. 

"^  Trichinella  spiralis. — A.  A.  E. 

20 


306  DIGESTIVE  ORGANS 

As  a  rule,  trichiniasis  occurs  in  epidemic  form,  and  this  is 
readily  explicable  from  the  fact  that  a  trichinous  pig  is  used  as 
food  by  nuiny  persons  at  the  same  time  or  within  a  short  period. 
In  many  instances  epidemics  of  trichiniasis,  in  which  several  hun- 
dred persons  were  attacked,  have  originated  from  a  butcher-shop 
in  which  a  tricliinous  pig  had  been  offered  for  sale.  In  other 
instances  smaller  circles  of  relatives  and  friends  were  attacked 
who  had  partaken  together  of  a  given  meal  or  had  received  some 
part  of  the  pig  as  a  gift.  Epidemics  in  barracks  have  also  been 
observed.  Epidemics  of  trichiniasis  are  more  common  in  certain 
regions  than  in  others.  The  Harz  region  has  a  bad  reputation  in 
this  respect,  whereas  Switzerland,  France,  and  England  have 
heretofore  remained  entirely  free.  This  fact  is  dependent  upon 
local  custom,  as,  for  instance,  in  the  Harz  upon  the  practice  of 
eating  raw  meat.  Besides,  trichiniasis  occurs  with  varying  fre- 
quency among  swine  in  different  regions.  It  occurs  with  especial 
frequency  in  America,  and  attention  therefore  has  properly  been 
called  to  the  fact  that  the  use  of  American  ham  arid  bacon  may 
be  attended  M'ith  serious  dangers.^ 

The  opportunity  for  swine  to  become  trichinous  is  the  more 
favorable  the  greater  the  want  of  care  and  of  cleanliness  in  the 
pens  in  which  they  are  kept.  If  the  animals  are  not  prevented 
from  eating  one  another's  feces,  it  may  readily  happen  that  if 
accidentally  a  trichinous  pig  is  introduced  into  the  herd,  this 
animal  may  infect  the  remainder  through  its  trichinous  stools. 
A  still  greater  source  of  danger  of  infection  is  constituted  by 
tricliinous  rats,  as  these  animals  are  frequent  occupants  of  pig- 
pens and  are  readily  eaten  by  the  pigs.  The  rats  in  turn 
acquire  their  trichinae  from  the  ingestion  of  the  trichinous  fecal 
matter  of  the  pigs.  As  rats  frequently  migrate  from  one  pen 
to  another,  the  danger  of  their  being  the  means  of  suddenly 
conveying  trichiniasis  into  herds  of  healthy  swine  nuist  be 
obvious.  Whether  rats  or  pigs  were  originally  the  hosts  of 
tricliinse  is  still  a  disputed  question.  The  mode  of  fattening  pigs 
has  an  important  bearing  upon  the  development  of  trichinae  in 
these  animals.  In  America  particularly  it  is  customary  to  feed 
pigs  at  rendering  establishments  with  the  meat  of  dead  animals ; 
and  as  care  is  not  taken  to  determine  wliether  such  meat  is  free 
from  trichinse,  trichiniasis  is  often  conveyed  to  the  hogs  in  this 
way.2 

'  While  trichiniasis  is  common  in  hos:s  in  the  United  States,  it  is  compara- 
tively rare  in  man,  because  pork  is  usually  well  cured  or  cooked. — A.  A.  E. 

■^  This  statement  requires  modification.  All  meat  for  interstate  consumption 
and  for  export  is  submitted  to  governmental  inspection,  and  the  practice  of  feed- 
ing the  ofial  of  slaughtered  animals  to  hogs  would  be  interdicted,  even  if  the 
land  about  abattoirs  were  not  too  valuable  to  forbid  its  use  for  growing  hogs. 
It  is  possible  that  such  a  practice  is  followed  at  some  countrv  slaughter-houses. — 
A.  A.  E. 


ANIMAL  PARASITES  OF  THE  INTESTINE  307 

All  animals  that  partake  of  trichinous  meat  may  be  attacked  by 
trichinse.  The  disease  has  been  intentionally  produced  even  in  sala- 
manders. Cats  are  not  rarely  trichinous  from  having  eaten  trichinous 
mice  or  rats.  Trichinse  have  been  found  also  in  the  muscles  of  wild  ani- 
mals (badger,  polecat,  fox),  probably  from  the  ingestion  of  trichinous  mice 
or  rats. 

Anatomic  Alterations. — If  impregnation  of  ingested  tri- 
cbinse  has  taken  place  in  the  intestine  of  a  human  being,  the  birth 
of  a  new  brood  of  trichinse  begins  on  the  seventh  day.  The 
young  animals  quickly  leave  the  intestine,  to  migrate  into  the 
muscles.  The  paths  that  they  follow  in  their  wanderings  are  known 
only  in  part ;  at  any  rate,  the  lymphatics  and  also  perhaps  the 
blood-vessels  are  followed.  Trichinse  are  found  with  great  con- 
stancy in  certain  groups  of  muscles.  Among  these  are  especially 
the  diaphragm,  the  intercostal  muscles,  those  of  the  vocal  bands, 
the  neck,  the  eyes,  and  those  of  mastication.  On  the  other 
hand,  the  myocardium  is  almost  unexceptionally  exempt  from 
invasion.  In  the  muscles  of  the  extremities  the  trichinse  are 
found  in  greatest  number  in  the  vicinity  of  the  tendons.  In  the 
muscles  the  young  trichinse  induce  especially  parenchymatous 
myositis.  In  those  situations  in  which  trichinse  are  contained 
within  a  muscular  fiber  this  swells,  and  its  protoplasm  acquires 
a  glistening  appearance  free  from  transverse  striation.  At  the 
same  time  proliferation  of  the  sarcolemma-nuclei  takes  place. 
Vacuolation,  waxy  degeneration,  and  granular  disintegration  of 
the  muscle-fibers  occur.  Further,  inflammatory  hyperplasia  and 
cell-multiplication  take  place  in  the  interstitial  connective  tissue. 
After  a  time  the  trichinse,  at  first  extended,  become  rolled  up 
spirally,  and  surrounded  by  a  lemon-shaped  capsule  (Fig.  50). 
Later,  calcification  of  the  capsule  takes  place.  Within  their  cap- 
sule trichinse  have  at  times  persisted  throughout  a  life  of  several 
decades.  Occasionally,  however,  the  process  of  calcification  in- 
volves the  trichinas  themselves,  and  they  may  as  a  result  become 
disintegrated  into  several  calcified  segments.  Whether  trichinse 
in  muscles  possess  vitality  or  not  may  be  recognized  from  the 
fact  that  on  microscopic  examination  of  teased  preparations  of 
trichinous  muscle  living  trichinse  are  motile  if  the  preparation 
be  placed  upon  a  warm  stage.  Not  rarely  several  trichinse  may 
be  found  within  a  single  muscle-fiber.  Two  trichinse,  rarely  more, 
may  also  be  enclosed  within  a  common  capsule.  Trichinse  may 
be  discernible  in  the  muscles  even  with  the  unaided  eye,  for  the 
capsules  appear  as  small,  light-yellow  points.  At  times  the 
muscles  are  fairly  crowded  with  such  yellow  points.  Naturally, 
confirmation  with  the  microscope  should  be  made,  and  for  this 
purpose  a  magnification  of  50  is  quite  sufficient.  I  have  repeat- 
edly found  at  autopsy  old  muscle-trichinse  accidentally  and  as  a 
secondary  phenomenon  in  human  beings.     When  individuals  die 


308 


DIGESTIVE  ORGANS 


as  the  result  of  trichiniasis  they  frequently  present  edema  of  the 
eyelids  and  of  the  extremities.  Often  the  muscles  of  mastication 
are  unusually  well  defined  beneath  the  skin  of  the  face  in  conse- 
quence of  marked  contraction,  and  the  elhow-joints  are  greatly 
flexed.  Tlie  face  appears  deeply  sunken.  The  voluntary  muscles 
are  thickened  and  turbid,  and  exhibit  here  and  there  extravasa- 
tions of  blood.  Such  extravasations  may  be  present  also  in  the 
myocardium.  The  spleen  presents  the  appearance  common  to 
infectious  diseases,  and  is  large  and  soft  in  consistency.  The  liver 
and  the  kidneys  appear  swollen  and  cloudy,  and  also  fatty.  The 
mucous  membrane  of  the  stomach,  and  especially  of  the  small 
intestine,  exhibits  inflammatory  swelling  and  often  extravasations 


Fig.  50. — jSIuscle-trichinse  with  capsules,  from  the  diaphragm ;  magnified  60  times  (from 

personal  preparations). 

of  blood.  It  is  important  to  obtain  the  intestinal  contents,  to 
dilute  them  with  water,  and  to  examine  them  for  intestinal  tri- 
chinae and  their  offspring.  The  trichinae  can  just  be  recognized 
as  small,  grayish-white  filaments,  the  female  being  from  3  to  4 
and  the  male  on  the  average  1.5  mm.  long. 

Symptoms. — Persons  who  have  eaten  trichinous  meat  remain 
well,  as  a  rule,  for  a  week.  It  is  but  rarely  complained  that 
immediately  after  the  ingestion  of  trichinous  food  malaise,  nausea, 
vomiting,  and  diarrhea  have  set  in.  Generally  the  symptoms 
named  appear  after  the  lapse  of  a  week,  following  the  birth  of 
the  young  trichinae  in  the  intestine.  The  diarrhea  may  at  times 
be  so  excessive  that  the  clinical  picture  is  suggestive  of  Asiatic 
cholera,  and  death  may  result  from  exhaustion.  Soon  alterations 
in  the  muscles  are  superadded.  The  patient  complains  of  severe 
pain  in  the  muscles  and  in  the  extremities,  which  already  appear 


ANIMAL  PARASITES  OF  THE  INTESTINE  309 

sensitive  to  the  slightest  touch,  and  feel  tense  and  doughy.  In 
consequence  of  involvement  of  the  muscles  of  the  vocal  bands 
hoarseness  results ;  the  eyes  are  painful  on  movement,  and  this 
]>ecomes  difficult ;  breathing  becomes  embarrassed  and  painful ; 
and  also  in  the  extremities  stiffness  and  intolerable  pain  appear 
on  any  attempt  at  movement.  In  many  instances  muscular  con- 
tractures and  fixed  positions  of  the  extremities  develop.  Flexion 
at  an  acute  angle  takes  place  at  the  elbow-joints,  and  also  in  the 
hip-joints  and  the  knee-joints ;  the  masseters  are  contracted  with 
board-like  hardness,  and  lock-jaw  or  trismus  results.  I  have  also 
observed  stiffness  in  the  muscles  of  the  neck  and  the  back,  so  that 
distinct  opisthotonos  developed,  the  vertebral  column  being  greatly 
curved  forward,  and  the  patient  resting  only  with  the  occiput  and 
the  sacrum  upon  the  bed.  To  the  distressing  pains  in  the  muscles 
there  are  thus  superadded  stiffness  and  immobility  of  the  entire 
body,  and  the  patient  requires  assistance  for  all  movement.  The 
occurrence  of  edema  of  the  skin  is,  further,  noteworthy.  This  is 
noticeable  especially  in  the  eyelids,  but  also  in  the  extremities. 
Its  cause  is  not  definitely  known.  Symptoms  of  general  infection 
further  play  an  important  part  in  the  clinical  picture  of  trichini- 
asis.  These  may  perhaps  be  dependent  upon  the  activity  of  toxic 
substances  excreted  by  the  trichinae,  but  perhaps  they  may  be  due 
to  the  absorption  of  products  of  abnormal  metabolism  developed 
in  consequence  of  the  extensive  inflammation  of  the  muscles. 
Trichiniasis  is,  as  a  rule,  attended  with  fever,  and  the  temper- 
ature may  reach  39°  C.  (102.2°  F.),  40°  C.  (104°  F.),  and  even 
more.  The  temperature  does  not  pursue  a  definite  course,  and 
periods  of  continued  and  remittent  fever  alternate  with  each 
other.  Often  the  fever  extends  over  several  weeks.  In  corre- 
spondence with  the  elevation  of  bodily  temperature  thirst  is 
increased,  while  the  appetite  suffers.  Trichinous  patients  almost 
constantly  suffer  from  copious  sweating.  The  face  and  the  trunk 
are  usually  covered  with  large  drops  of  sweat,  and  often  the  skin 
in  the  portions  of  the  body  covered  by  clothing  is  raised  by  stag- 
nant sweat  into  innumerable,  small,  transparent,  dewdrop-like  vesi- 
cles— sudamina  or  miliaria.  Frequently  the  patient  complains  of 
persistent  sleeplessness — agrypnia.  The  abdomen  is  often  greatly 
distended.  The  spleen  can  be  demonstrated  to  be  enlarged 
by  percussion,  and  frequently  also  by  palpation.  The  coated 
tongue  and  the  persistent  diarrhea,  in  conjunction  with  a  por- 
tion of  the  symptoms  described,  often  excite  suspicion  of  typhoid 
fever,  a  suspicion  that  can  readily  be  removed  by  showing  that 
the  blood-serum  of  the  trichinous  patient  fails  to  cause  clumping 
and  loss  of  motility  of  typhoid-bacilli.  The  urine  is  usually 
passed  in  small  amounts,  although  later  polyuria  may  develop. 
Albuminuria  is  an  uncommon  symptom,  and  is  usually  of  febrile 
origin. 


310  DIGESTIVE  ORGANS 

[Trichiniasis  is  attended  with  a  marked  increase  in  the  number  of  white 
blood-corpuscles,  and  it  is  characteristic  that  the  augmentation  involves 
particularly  the  eosinophile  cells. — A.  A.  E.] 

Trichiniasis  generally  pursues  a  subacute  or  a  chronic  course. 
Frequently  the  strength  grows  progressively  less,  pronounced 
marantic  edema  sets  in,  and  the  patients  die  from  exhaustion 
after  ■sveeks  of  misery.  Occasionally  death  takes  place  from 
pneumonia  amid  manifestations  of  progressive  respiratory  dis- 
turbance. Among  the  complications  septic  manifestations  are 
especially  to  be  named,  as,  for  instance,  furunculosis  and  suppu- 
rative parotiditis.  Should  recovery  from  the  disease  take  place, 
muscular  and  articular  pains  and  stiffness,  at  times  muscular  in- 
duration and  great  irritability  of  the  abdomen  and  the  intestine, 
frequently  persist  for  a  long  time. 

Diagnosis. — The  recognition  of  trichiniasis  is  easy  and  cer- 
tain if  small  bits  of  muscle  are  excised  and  examined  microscopi- 
cally for  trichinse.  The  biceps  of  the  arm  is  the  muscle  best  suited 
for  this  purpose,  as  it  contains  trichina?  with  great  constancy.  It 
may  also  be  important  to  examine  the  stools  for  trichinae.  Inquiry 
should  further  be  made  to  determine  whether  any  of  the  meat 
partaken  of  can  still  be  secured,  and  this  also  should  be  examined 
for  trichinae.  It  is  always  susj^icious  when  a  number  of  persons 
who  have  taken  part  in  the  same  meal,  or  have  obtained  their 
supply  of  meat  from  the  same  butcher-shop,  are  attacked  with 
the  symptoms  described.  Formerly  trichiniasis  was  most  com- 
monly mistaken  for  typhoid  fever,  or  for  olistinate  and  serious 
varieties  of  muscular  or  articular  rheumatism.  A  similar  clinical 
picture  is  presented  by  acute  pjolymyositis,  but  this  disorder  occurs 
independently,  apart  from  the  ingestion  of  meat,  and  only  in  iso- 
lated instances. 

Prognosis. — The  prognosis  of  trichiniasis  is  exceedingly 
grave,  as  no  remedy  is  known  that  is  capable  of  preventing  the 
migration  of  young  trichinae  from  the  intestine  into  the  muscles  and 
of  destroying  trichinae  present  in  the  muscles.  In  some  epidemics 
of  tricliiniasis  death  occurred  in  one-third  of  those  attacked.^ 

Treatment. — If  a  number  of  persons  have  partaken  of  tri- 
chinous  meat  from  the  same  animal,  experience  lias  shoMu  that 
the  severity  of  the  disease  may  be  most  variable.  This  will 
depend,  in  the  first  place,  upon  the  fact  whether  one  person  has 
oaten  more  and  another  less  of  the  meat,  Avhether  alcohol  was 
used  at  the  meal,  and  whether  this  was  possibly  followed  by  vom- 
iting and  diarrhea.  Under  fiivorable  conditions  trichiniasis  may 
not  develop  in  one  or  another  of  those  who  have  partaken  of 
infected  meat.  It  is  rare  for  persons  to  observe  soon  after  inges- 
tion tliat  the  meat  partaken  of  was  tricliinous.  Under  such  cir- 
cumstances the  contents  of  the  stomach  should  be  at  once  removed 

^  The  mortality  among  large  numbers  of  cases  is  about  5  per  cent. — A.  A.  E. 


ANIMAL  PARASITES  OF  THE  INTESTINE  311 

by  irrigation,  and  the  intestinal  contents  evacuated  as  rapidly  as 
possible  by  means  of  castor-oil  (30.0 — 1  fluidounce).  In  addition 
the  administration  of  glycerin  internally  has  also  been  recom- 
mended (15  c.c. — 1  tablespoonful — every  hour),  as  trichinae  die 
rapidly  in  this  substance.  When  trichiniasis  has  fully  developed, 
onlv  symptomatic  treatment  is  available.  Severe  pains  can  be 
relieved  by  hot  baths  (from  28°  R.— 95°  F.— to  30°  R.— 99.5°  F.), 
and  subcutaneous  injections  of  morphin.  The  diet  should  be  light 
yet  nutritious.  Profuse  sweating  is  best  relieved  by  means  of 
atropin  sulphate  (0.0005 — yto  g^'^'i" — o"ce  or  twice  daily). 
Within  the  first  eight  days  an  effort  should  be  made  to  expel 
any  trichinae  possibly  present  in  the  intestine,  as,  for  instance,  by : 

R  Santonin,  0.05  (f  graiuj ; 

Mercurous  chlorid, 

Jalap, 

Sugar,  each,  0.5    (TJ  grains). — M. 

Make  5  such  powders. 
Dose :  1  powder  twice  daily. 

Great  importance  is  to  be  attached  to  the  prophylaxis.  As  has 
been  indicated  in  the  consideration  of  the  etiology,  this  includes 
cleanliness  in  the  pig-pens,  caution  in  the  feeding  of  hogs  with  the 
meat  of  slaughtered  animals,  thorough  meat-inspection,  the  destruc- 
tion of  trichinous  meat,  and  the  avoidance  of  uncooked  or  insuffi- 
ciently cooked  pork.  Pickling  and  smoking  of  pork  are  not 
capable  of  removing  with  certainty  all  danger  of  infection. 


ANKYLOSTOMUM    DUODENALE 


Btiolog'y. — Until  within  a  few  years  it  was  believed  that 
anhyhstomiasis  occurred  only  in  the  Orient  and  in  Italy.  In  the 
course  of  construction  of  the  St.  Gotthard  tunnel  it  developed  that 
the  disease  was  introduced  into  Switzerland  by  Italian  laborers. 
Foci  of  the  disease  were  then  observed  in  certain  mines  of  France, 
Sardinia,  Belgium,  and  Hungary,  and  in  recent  years  the  disorder 
has  been  encountered  in  brick-yards  at  Bonn,  Cologne,  Wiirz- 
burg,  and  Berlin.  As  the  most  prominent  symptoms  consist  in 
progressive  anemia,  the  disease  has  been  given  the  designations 
tunnel-anemia,  miners''  anemia,  brichnakers^  anemia,  in  accordance 
with  the  conditions  under  which  it  occurs.  In  Egypt,  where  the 
disease  has  been  known  for  some  time,  it  has  been  named  tropical 
chlorosis.  It  has  been  repeatedly  demonstrated  with  certainty  that 
the  disease  is  spread  by  foreign  wandering  laborers,  who  come  from 
localities  in  which  ankylostomum  occurs,  and  where  they  have 
themselves  contracted  ankylostomiasis.  The  danger  of  infection 
becomes  the  greater  the  more  intimately  the  sick  and  the  well 
live  together  and  the  less  the  degree  of  care  observed  in  the  dispo- 
sition of  the  fecal  discharges  in  secure  and  closed  receptacles,  in 
^  Uncinaria  duodenalls. — A.  A.  E. 


312 


DIGESTIVE  ORGANS 


order  to  prevent  their  entrance  into  the  water  used  f(jr  drinking 
and  other  domestic  purposes.  Infection  usually  takes  place  through 
water  polluted  with  fecal  matter  containing  ankylostomum-ova,  or 
througii  particles  of  earth  containing  larvte  of  ankylostomum  and 
adherino:  to  the  fino-ers,  and  which  mav  be  readilv  swallowed  when 
food  is  ingested. 

Anatomic  Alterations. — The  Ankylostomum  duodenale  is 
a  small  cylindrical  worm  (Fig.  51) ;  the  females,  of  which  there 
may  be  more  than  twice  as  many  as  of  the  males,  are  longer  (up 
to  18  mm.)  than  the  males  (from  6  to  10  mm.).  The  number 
of  the  })arasites  in  the  intestine  may  vary  between  15  and  3000. 


Fig.  51. — Ankylostomum 
duodenale  :  the  male  to  the 
left,  the  female  to  the  right 
(natural  sizei. 


Fig.  52. — Ova  of  ankylostomum. 


The  eggs  of  ankylostomum  are  found  in  the  stools  in  almost 
uniform  distribution,  and  they  may  be  readily  recognized  on 
microscopic  examination.  They  are  of  oval  shape,  and  possess 
a  bright  shell  and  granular  contents,  which  are  usually  in  a 
state  of  fission  (Fig.  52).  Ankylostoma  are  found  much  more 
constantly  in  the  jcjunuDi.  and  the  ileum  than  in  the  duodenum. 
They  attach  themselves  by  suction  to  the  intestinal  raucous  mem- 
brane by  means  of  their  mouth,  which  is  armed  Avith  six  chitinous 
teeth,  and  thus  extract  blood  from  their  host.  The  females  appear 
to  be  especially  bloodthirsty,  and  they  suck  much  more  blood 
than  is  necessary  for  their  existence.  They  therefore  present  a 
brownish  appearance,  dependent  upon  the  blood  collected  within 
their  body.  On  post-mortem  examination  anl-cylostoma  are  found 
free  in  the  intestinal  contents  or  firmly  attached  to  the  intestinal 
mucous  membrane.  In  the  latter  event  they  are  often  engaged  in 
rolling  movements.  The  intestinal  mucous  membrane  exhibits  in 
places  recent  as  well  as  older  extravasations  of  blood  and  hemor- 
rhagic suffusions  that  correspond  to  the  points  of  attachment  of 
the  parasites.  In  addition,  all  of  the  viscera  are  conspicuous  for 
their  exceeding  anemia  and  pallor.  In  consequence  hemorrhage 
has  taken  place  in  various  situations.  These  are  found  with  espe- 
cial frequency  upon  the  inner  aspect  of  the  cerebral  dura  mater, 
Avhere  they  are  often  converted  into  pachymeningitic  membrane. 
Anemic  fatty  degeneration  also  generally  develops,  particularly  in 
the  myocardium,  the  cells  of  the  liver,  and  the  epithelial  cells  of 
the  convoluted  uriniferous  tubules.    The  bone-marrow  appears  defi- 


ANIMAL  PARASITES  OF  THE  INTESTINE  313 

cient  in  fat,  and  at  times  contains  nucleated  red  blood-corpuscles  in 
unusual  number. 

Symptoms. — The  symptoms  of  ankylostomiasis  consist  in 
gradually  progressive  anemia  and  its  consequences,  and  are  depen- 
dent upon  abstraction  of  blood  by  the  parasites.  Whether,  in 
addition,  toxic  influences  are  also  operative  has  not  yet  been 
demonstrated.  On  the  average  anemic  manifestations  appear 
within  five  or  six  weeks  after  infection  has  taken  place.  The 
patients  acquire  a  pallid  appearance,  which  may  attain  such  a 
marked  degree  as  to  create  a  cadaveric  aspect.  Examination  of 
the  blood  discloses  the  fact  that  the  number  of  red  corpuscles  may 
be  diminished  to  one-fifth  of  the  normal,  and  that  also  the  hemo- 
globin-percentage is  diminished  correspondingly.  At  the  same 
time  the  red  blood-corpuscles  are  characterized  by  their  variability 
in  shape — poikilocytosis.  They  also  vary  greatly  in  size,  and 
assume  the  appearance  of  a  pear,  a  club,  a  figure  of  eight,  and  the 
like.  At  times  nucleated  red  blood-corpuscles  also  are  found. 
The  greater  the  degree  of  anemia  the  more  markedly  do  the  func- 
tions of  the  body  become  impaired.  The  patient  tires  readily  from 
work,  suffers  from  dyspnea  and  palpitation  of  the  heart,  and  is 
attacked  by  sweats.  Finally,  tlie  weakness  becomes  so  excessive 
that  the  patients  are  compelled  to  remain  in  bed  constantly  be- 
cause vertigo,  tinnitus  aurium,  confusion  of  vision,  and  syncope 
may  occur  in  the  erect  posture, — all  signs  of  increasing  cerebral 
anemia  on  assumption  of  the  erect  posture.  The  heart  appears 
enlarged  toward  the  right  (anemic  dilatation  of  the  less  resistant, 
because  thin-walled,  right  ventricle),  and  over  it  anemic  systolic 
murmurs  may  be  audible.  Over  the  bulb  of  the  internal  jugular 
vein  a  loud  venous  hum  or  "nun's  murmur,''  sometimes  palpable 
as  a  thrill,  may  be  detected.  A  cardiac-systolic  arterial  sound  is 
audible  over  the  large  peripheral  arteries  (brachial,  radial).  Not 
rarely  cutaneous  edema  develops,  because  the  blood-vessels,  whose 
nutrition  has  been  impaired,  are  excessively  permeable  to  the 
blood-plasma.  Accumulations  of  fluid  (transudates)  may  take 
place  also  in  the  serous  cavities  (pleura,  pericardium,  peritoneum, 
meningeal  spaces).  Nutritive  disturbances  in  the  blood-vessels 
give  rise  also  to  the  occurrence  of  hemorrhages,  M'hich  may  take 
place  into  the  external  integument,  the  mucous  membranes,  and 
in  isolated  instances  also  the  retina,  and  under  circumstances  may 
increase  the  anemia  to  a  considerable  degree. 

The  appetite  is,  as  a  rule,  impaired,  while  thirst  is  greatly  in- 
creased. At  times  there  may  be  paradoxic  appetite — allotriophagy 
— for  inedible  and  indigestible  substances,  as,  for  instance,  earth 
(geophagy).  The  stools  may  then  contain  also  sandy  and  earthy 
constituents.  At  times  they  contain  blood.  The  occurrence  of 
ankylostomum-ova  is  important,  while  ankylostoma  themselves 
are  but  rarely  encountered.     Usually  the  stools  contain  a  large 


314  DIGESTIVE  ORGANS 

number  of  Charcot-Neuniann  crystals  (p.  115,  Fig.  20).  The 
bowels  are  at  times  constipated,  at  times  loose.  Frequently  there 
is  complaint  of  a  sense  of  pressure,  of  fulness,  and  of  pain  in  the 
abdomen,  which  is  distended  from  mcteurism.  The  urine  is  usu- 
ally' passed  in  large  amounts,  and  contains  a  good  deal  (jf  indican. 
The  temperature  of  the  body  is  often  subnormal,  although  febrile 
movement  may  occur  for  periods  of  greater  or  lesser  duration 
(anemic  fever).  Should  no  attempt  be  made  to  expel  the  para- 
sites, or  should  this  be  successful  only  after  the  anemia  has 
become  excessive,  the  patients  may  die  like  the  victims  of  hemor- 
rhage. The  l)odily  weakness  becomes  excessive  and  conscious- 
ness obscured,  and  finally  death  takes  place.  The  disorder  is 
usually  chronic  in  course.  Improvements  and  exacerbations  take 
place,  the  former  after  expulsive  treatment,  and  the  latter  when 
the  results  of  treatment  are  not  entirely  successful. 

Diagnosis. — Ankylostomum-anemia  resembles  perfectly  pro- 
gressive pernicious  anemia,  and  a  differentiation  can  be  made  only 
from  the  fact  that  in  cases  of  pernicious  anemia  the  stools  are  free 
from  ankylostoma  and  ankylostoma-ova.  The  latter  circumstance 
likewise  distinguishes  ankylostomiasis  from  all  other  anemic 
states — in  old  persons,  for  instance,  from  carcinomatous  cachexia. 
A  positive  opinion  as  to  the  absence  of  parasites  and  ova  from  the 
stools  will  naturally  be  possible  only  if  the  intestinal  discharges 
remain  unchanged  after  the  administration  of  extract  of  filix  mas. 

Prognosis. — The  prognosis  of  ankylostomiasis  is  serious, 
because  some  patients  are  already  in  such  an  anemic  and  ex- 
hausted state  when  they  first  come  under  medical  observation 
that  death  soon  occurs  in  spite  of  expulsive  treatment.  The 
likelihood  of  recovery  is  further  not  rarely  lessened  by  the  fact 
that  occasionally  the  patient  declines  thorough  treatment  because 
he  does  not  have  time  to  give  up  his  work  and  submit  to  proper 
treatment  in  a  hospital  for  a  sufficiently  long  period.  In  cases  in 
which  the  instructions  of  the  physician  will  be  followed  and  pro- 
fessional aid  is  not  sought  too  late,  recovery  can  be  promised. 

Treatment. — Extract  of  filix  mas  has  proved  the  most  cer- 
tain remedy  for  ankylostomiasis,  but  it  must  be  given  in  large 
doses  (from  10.0 — 2i^fluidrams — to  20.0 — 5  fluidrams).  The  pre- 
paration for  tapeworm  mentioned  on  p.  300  may  also  be  employed. 
Frequently  ankylostoma  remain  in  the  intestine,  and  the  males 
especially  apjiear,  by  reason  of  their  small  size,  to  be  able  to  con- 
ceal themselves  readily  behind  folds  of  the  intestinal  mucous  mem- 
brane, and  thus  to  escape  tiie  action  of  the  remedy.  For  this 
reason  the  stools  must  again  be  examined  for  ankylostoma-ova  a 
short  time  after  the  treatment,  and  if  eggs  be  found  present  the 
expulsive  treatment  should  be  repeated.  The  anemic  conditions 
induced  as  a  result  of  ankylostomiasis  should  be  corrected  by 
means  of  nutritious  food,  arsenic,  and  mild  preparations  of  iron. 


JA  UNDICE 


315 


The  prophylaxis  is  important.  This  consists  in  excluding  the  car- 
rier of  ankylostoma  from  work-places,  enjoining  the  laborers  to 
eat  only  with  carefully  cleansed  hands, 
and  exercising  care  to  secure  perfect 
closure  of  water-closets  and  of  water- 
conduits. 


ANGUILLULA      IXTESTINALIS 

GUILLULA     STEECORALIS 


AND 

1 


AN- 


Anguillula  intestinalis  and  Anguillula 
stercoralis  have  been  found  in  the  stools 
in  some  cases  of  tropical  diarrhea,  espe- 
cially Cochin- China  diarrhea,  although 
they  have  been  found  also  in  the  laborers 
on  the  St.  Gotthard  tunnel  in  conjunction 
with  the  Ankylostomum  duodenale.  In 
all  probability  these  are  not  two  different 
varieties  of  worm,  but  the  Anguillula 
stercoralis  represents  an  earlier  stage  in 
the  development  of  the  Anguillula  intes- 
tinalis. The  latter  occurs  especially  in 
the  small  intestine,  and  the  Anguillula 
stercoralis  throughout  the  entire  large  in- 
testine. On  microscopic  examination  the 
Anguillula  intestinalis  is  found  to  be  a 
circular  worm,  with  a  conical  caudal  ex- 
tremity, within  whose  interior  the  diges- 
tive tube  with  two  enlargements  can  be 
seen  (Fig.  53).  Thymol  (1.0 — 15  grains — 
every  hour)  especially  has  been  recom- 
mended for  the  expulsion  of  the  para- 
sites. 


Fig.  53.— Anguillula  intesti- 
nalis ;  magnified  100  times 
(after  Seifert). 


The  larvse   of  flies  have  in  a  number  of 
instances  been  found  in  the  stools,  having  been 
swallowed  with  food.     The  patients  have  com- 
plained of  pain  in  the  abdomen,  and  have  at  times  suffered  from  obstinate 
diarrhea. 


VI.   DISEASES   OF  THE   LIVER. 


JAUNDICE  (ICTERUS), 

Htiology. — Jaundice  is  an  exceedingly  common  symptom  of 
disease  of  the  liver  and  biliary  passages.  Among  diseases  of  the 
liver  fatty  liver  and  amyloid  liver  alone  are  unattended  with  jaun- 

^  Stronffvloide?  intestinalis. 


31()  DIGESTIVE  ORGANS 

dice  in  the  absence  of  complications.  Jaundice  occurs  most  com- 
monly in  consequence  of  obstruction  of  the  biliary  passages,  whether 
this  involves  the  larger  ducts  or  those  within  the  liver.  The  cases 
arc  much  less  common  in  which  in  the  presence  of  thrombosis  of 
the  portal  vein  the  blood-pressure  in  the  intrahepatic  branches  of 
this  vessel  becomes  so  slow  that,  contrary  to  the  rule,  the  bile 
secreted  by  the  liver-cells  passes  over,  not  into  the  biliary  capilla- 
ries, but  into  the  branches  of  the  portal  vein.  In  rare  instances 
the  bile  stagnates  in  the  intrahepatic  biliary  passages  because  the 
movements  of  the  right  half  of  the  diaphragm  are  interfered  with, 
and,  as  a  result,  the  inspiratory  pressure  of  the  diaphragm  upon 
the  liver  and  the  mechanical  propulsion  of  the  secreted  bile  toward 
the  intestine  are  removed.  For  this  reason  jaundice  is  sometimes 
observed  in  association  with  right-sided  diaphragmatic  pleurisy. 
Occasionally  the  biliary  passages  become  so  greatly  distended  with 
bile  that  they  are  incapable  of  conveying  all  of  this  secretion  to 
the  intestine,  and  a  portion  thereof  passes  over  into  the  blood- 
vessels and  lymphatics.  This  condition  has  been  described  as 
jaundice  due  to  polycholia  or  pleiochromia.  Such  conditions  arise 
especially  after  the  ingestion  of  certain  poisons  that  cause  dissolu- 
tion of  the  red  blood-corpuscles.  The  hemoglobin  set  free  in  the 
blood-current  is  acted  upon  by  the  liver-cells,  and  converted  into 
biliary  coloring-matter,  and  pleiochromia  results. 

Under  all  of  the  conditions  thus  far  mentioned  the  jaundice  re- 
sults from  mechanical,  hypostatic,  or  resorpAhe  influences.  In  recent 
years  attention  has  been  directed  to  another  variety  of  jaundice, 
which  has  been  designated  difusive  or  acatectic.  Under  normal 
conditions  it  is  the  function  of  the  liver-cells  not  only  to  produce 
bile  from  blood  coloring-matter,  but  also  to  convey  the  bile  into 
the  biliarv  passages.  Under  morbid  conditions  the  latter  property 
may  be  lost,  so  that  the  bile  produced  by  the  liver-cells  is  not 
discharged  into  the  biliary  passages,  but  into  the  lymphatics  and 
the  blood-vessels.  It  has  been  assumed  that  such  a  diffusion- 
icterus  may  develop  in  consequence  of  the  action  of  poisons,  ptomains, 
and  toxins.  The  theory  of  diffusion-icterus,  however,  still  requires 
more  convincing  evidence,  and  it  appears  premature  to  attempt 
to  explain  almost  all  varieties  of  icterus  as  due  to  diffusion. 

Among  all  of  the  varieties  of  jaundice  thus  far  mentioned  that 
is  the  most  common  which  develops  in  consequence  of  obstructit)n 
of  the  biliarv  passages,  and  which  has  long  been  known  as  hepa- 
togenous, mechanical,  resorptive,  or  hj/postatie  icterus.  Obstruction 
of  the  larger  biliary  passages  occurs  with  especial  frequency  in  con- 
nection with  gastro-intestinal  catarrh,  either  from  constriction  or 
occlusion  of  the  mouth  of  the  choledoch  duct  in  consequence  of 
swelling  of  the  duodenal  nuic<^us  membrane,  or  from  the  entrance 
of  a  plug  of  mucus  from  the  inflamed  mucous  membrane  into  the 
choledoch  duct,  or,  finally,  the  mucous  membrane  of  the  choledoch 


JAUNDICE  317 

duct  has  become  involved  in  the  inflammation  of  the  intestinal 
mucous  membrane,  and  the  inflammatory  swelling  of  the  mucous 
membrane  of  the  duct  has  given  rise  to  obstruction  of  its  lumen. 
The  jaundice  resulting  from  gastro-iutestinal  catarrh  is  designated 
catarrhal  or  gastroduodenal.  Not  rarely  the  biliary  passages  are 
obstructed  by  foreign  bodies.  Most  commonly  these  consist  of 
r/all-stones,  and  only  exceptionally  of  distomata  or  spool-worms, 
which  have  migrated  from  the  duodenum  into  the  choledoch  duct, 
or  fruit-kernels  and  foreign  bodies  from  the  food.  Cicatricial  and 
carcinomatous  obstructions  of  the  biliary  passages  are  not  common. 
The  former  usually  result  from  gall-stones  that  have  injured  the 
mucous  membrane  of  the  biliary  passages  in  their  progress.  At 
times  the  larger  biliary  passages  are  obstructed  by  pressure  from 
toithout.  The  most  common  causes  of  this  condition  are  tumors 
of  the  stomach,  the  intestine,  the  pancreas,  the  kidneys,  wander- 
ing kidney,  peritoneal  exudates,  bands,  aneurysms  of  the  hepatic 
artery,  enlargement  of  the  uterus  or  ovaries.  Enlargement  of  the 
portal  lymphatic  glands  may  also  be  mentioned  as  a  cause  of 
obstruction  of  the  biliary  passages.  Obstruction  of  the  intra- 
hepatic biliary  passages  and  the  resulting  jaundice  are,  as  has 
been  mentioned,  frequent  symptoms  of  the  most  varied  diseases  of 
the  liver. 

It  was  formerly  assumed  that  jaundice  might  be  'paralytic  or  spastic,  the 
former  depending  upon  paralysis,  the  latter  upon  spasm  of  the  biliary  pas- 
sages, and  upon  the  secondary  biliary  stasis.  This  view  is  unfounded  and 
improbable. 

Opinions  are  divided  as  to  the  causes  of  toxic  jaundice,  and 
probably  various  disturbances  are  operative  in  this  connection. 
Thus,  in  cases  of  jaundice  due  to  phosphorus-poisoning  catarrh  of 
the  smallest  biliary  passages  in  the  liver  has  been  found.  Other 
poisons  (ether,  chloroform,  hydrogen  arsenid)  are  destructive  of 
the  red  blood-corpuscles,  and  give  rise  to  jaundice  in  consequence 
of  polycholia  or  pleiochromia.  DifPusion-icterus  appears  to  develop 
especially  in  consequence  of  the  action  of  bacterial  poisons — toxins. 
Jaundice  is  observed  not  at  all  rarely  in  the  course  of  certain  in- 
fectious diseases  (typhoid  fever,  septicopyemia,  diphtheria,  relaps- 
ing fever,  pneumonia,  etc.),  although  other  accidental  influences, 
as,  for  instance,  gastro-intestinal  catarrh,  may  give  rise  to  jaundice 
under  such  conditions,  and  this  possibility  must  be  carefully  con- 
sidered in  the  individual  case. 

Symptoms. — The  most  conspicuous  symptom  of  jaundice  is 
the  yellowish  discoloration  of  the  skin,  the  urine,  and  the  mucous 
membranes.  This  results  from  the  presence  of  biliary  coloring- 
matter  in  the  blood.  In  part  the  blood  takes  up  the  biliary  color- 
ing-matter directly  from  the  liver,  but  in  the  presence  of  biliary 
stasis  the  lympliatic  vessels  play  by  far  the  more  important  part 


318  DIGESTIVE  ORGANS 

in  the  absorption  of  bile,  which  in  turn  they  convey  to  the  blood. 

Cutaneous  jaundice  is  characterized  by  a  yellowish  discoloration 
of  the  skin,  the  intensity  of  which  varies  with  the  amount  of 
biliary  coloring-matter  circulating  in  the  blood  from  a  light  sul- 
phur-yellow to  a  coppery-brown  or  yellowish-gray.  In  the  latter 
event  the  designation  mel as  Icterus  has  been  employed.  The  yel- 
lowish discoloration  becomes  first  apparent  in  places  where  the 
skin  is  thin  and  well  supplied  with  vessels,  therefore  earliest  in 
the  face,  and  here  especially  in  the  temporal  region,  upon  the  fore- 
head, on  the  nasolabial  folds,  and  upon  the  chin.  Upon  the  fore- 
arms and  the  legs  the. yellowish  discoloration  of  the  skin  is  often 
less  pronounced  because  the  epidermis  is  thick  and  in  laborers  is 
brown  from  exposure  to  the  rays  of  the  sun.  AVhile  at  the  outset 
cutaneous  jaundice  is  dependent  solely  upon  the  yellowish  dis- 
coloration of  the  blood-})lasma  by  the  biliary  coloring-matter, 
subsequently  the  cells  of  the  epidermis  become  saturated  with 
biliary  coloring-matter,  which  crystallizes  in  the  form  of  brownish 
granules  in  the  epithelial  cells.  This  fact  explains  the  darker 
color  of  the  skin  when  jaundice  has  existed  for  some  time,  as  well 
as  the  experience  that  cutaneous  jaundice  may  persist  much  longer 
than  the  remaining  manifestations  of  jaundice,  for  it  disappears 
only  when  the  epidermic  cells  discolored  by  the  biliary  coloring- 
matter  are  desquamated. 

Icterus  of  the  mucous  membranes  is  most  readily  recognized 
in  the  conjunctivae.  The  sclerae  appear  more  or  less  deeply 
yellow,  instead  of  white.  Usually  this  icterus  of  the  conjunc- 
tivae is  an  early  manifestation  of  jaundice,  and  in  mild  cases 
discoloration  of  the  skin  and  of  the  urine  may  be  absent,  and 
only  that  of  the  conjunctiva  be  present.  Upon  other  mucous 
membranes  (lips,  mouth,  and  pharynx,  labia  and  vagina)  the 
jaundice  is  concealed  by  the  red  color  of  the  mucous  mem- 
brane ;  but  if  pressure  be  exerted  and  the  blood-vessels  are  thus 
emptied  the  icteric  discoloration  of  the  mucous  membrane  becomes 
distinct.  In  the  buccal  cavity  when  the  mouth  is  widely  opened, 
two  bands  of  yellowish  mucous  membrane,  increasing  in  size 
posteriorly  in  the  course  of  the  middle  line  of  the  hard  palate, 
are  visible.  Icteric  urine  is  discolored  brown,  blackish  brown,  at 
times  greenish  brown,  on  agitation  yields  a  yellowish  foam,  stains 
white  paper,  linen,  and  other  materials  yellow,  and  on  standing 
retains  its  foam  for  an  unusually  long  time.  The  presence  of 
biliary  coloring-matter  in  the  urine  may  be  best  demonstrated  by 
means  of  Gmelin's  or  jSIarechal's  test.  The  presence  of  biliary 
acids  can  generally  be  demonstrated  also  by  means  of  Pettenkofcr's 
test.  Tube-casts  occur  constantly  in  the  urine,  most  frequently 
hyaline,  and  often  stained  yellow  by  biliary  coloring-matter. 
Slight  all)mninuria  also  is  not  uncommon.  Cylindruria  and 
albuminuria  result  from  the  interference  by  the  biliary  acids  cir- 


JAUNDICE  319 

culating  in  the  blood  with  the  activity  of  the  epithelial  cells  in  the 
convoluted  urinary  tubules. 

GmelMs  test  for  biliary  coloring-matter  is  performed  in  the  following 
manner:  A  test-tube  is  filled  one-third  with  nitric  acid  containing  some 
nitrous  acid,  and  from  another  test-tube  filled  with  urine  this  fluid  is  per- 
mitted to  flow  slowly  upon  the  nitric  acid,  most  conveniently  by  holding 
the  two  tubes  obliquely  in  relation  with  each  other  at  their  mouths,  so  that 
the  urine  overlies  the  acid  and  forms  a  layer  upon  it.  If  the  urine  contain 
bilirubin,  a  play  of  colors  takes  place  at  the  line  of  contact  with  the  nitric 
acid,  and  from  below  upward  rings  of  yellow,  red,  blue,  and  green  will  be 
seen  to  develop  successively.  The  green  ring  alone  is  distinctive  of  biliary 
coloring-matter,  as  a  brownish  ring  occurs  also  when  the  urine  contains  con- 
siderable indican.  If  the  urine  contain  a  small  amount  of  bilirubin,  it  is 
advisable  to  pass  the  urine  through  filter-paper,  in  order  to  concentrate  the 
bilirubin  thereon,  to  spread  the  filter  upon  a  porcelain  dish,  and  then  to 
apply  a  glass  rod  that  has  been  dipped  in  impure  nitric  acid.  At  the  point 
of  contact  the  ring  of  color  mentioned  will  appear,  the  red  being  innermost 
and  the  green  outermost. 

MarichaV  s  test  for  biliary  coloring -matter  requires  even  less  skill  than 
Gmelin's.  To  urine  with  which  a  test-tube  has  been  half  filled  several 
drops  of  tincture  of  iodin  are  added,  or,  still  better,  a  solution  of  iodin  and 
potassium  iodid— so-called  Lugol's  solution,  which  consists  of  pure  iodin,  0.5 
(7^  grains) ;  potassium  iodid,  5.0  (75  grains) ;  and  water,  200  (60  fluidounces). 
The  presence  of  bilirubin  in  the  urine  is  disclosed  by  the  development  of  a 
grass-green  or  an  emerald-green  color.  Gmelin's  and  Marechal's  tests  are 
not  always  equally  distinct  with  the  same  urine,  and  it  is  possible  that  only 
one  or  the  other  may  yield  a  positive  reaction.  In  my  experience  Marechal's 
test  fails  the  less  commonly. 

Pettenkofer^ s  test  for  biliary  acids  depends  upon  the  fact  that  these  acids 
when  gently  heated  with  pure  sulphuric  acid  and  sugar  give  rise  to  a 
carmine  color.  As,  however,  it  would  be  difficult  for  the  practising  physi- 
cian to  obtain  the  biliary  acids  in  pure  form  from  the  urine,  Strassburger 
has  proposed  the  following  procedure,  which  in  my  experience  has  proved 
wholly  practicable :  A  bit  of  sugar  is  dissolved  in  the  urine,  and  then  a 
piece  of  white  filter-paper  is  dif)ped  in  the  solution  and  permitted  to  dry. 
The  filter-paper  is  then  touched  with  a  glass  rod  carrying  a  drop  of  pure, 
concentrated  sulphuric  acid.  If  the  urine  contain  biliary  acids,  a  carmine- 
red  color  appears  at  the  point  of  contact,  while,  otherwise,  a  blackish-brown 
color  at  once  appears  in  consequence  of  the  action  of  the  sulphuric  acid. 

A  number  of  other  symptoms  appear  in  the  clinical  picture  of 
jaundice,  but  they  are  rather  of  subordinate  importance  in  com- 
parison with  the  yellowish  discoloration  of  the  skin,  the  mucous 
membranes,  and  the  urine.  Alterations  in  the  frequency  of  bowel- 
movement  and  in  the  stools  are  among  the  most  common.  If 
jaundice  be  the  result  of  biliary  stasis,  the  patient  usually  suffers 
from  constipation,  for  if  no  bile  enters  the  bowel  the  stimulating 
effect  of  the  biliary  acids  upon  the  intestinal  musculature  will  be 
wanting.  At  the  same  time  the  stools  consist  of  large  nodular 
masses.  Usually  they  give  oflF  an  offensive,  putrid  odor,  because 
the  antiseptic  influence  of  the  bile  upon  the  intestinal  contents  has 
been  withdrawn.  The  color  of  the  stools  is  also  striking,  and, 
accordingly  as  the  flow  of  bile  to  the  intestine  is  restricted  or 
abolished,  it  varies  between  that  of  clay  and  that  of  ash.     At 


320  DIGESTIVE  ORGANS 

times  the  stools  present  almost  a  silvery  luster.  This  is  due  to 
the  large  amount  of  fat  present,  and  this  in  turn  is  dependent  upon 
the  faet  that  the  biliary  acids  in  the  intestine  aid  in  the  absorption 
of  the  fat  in  the  food,  so  that  in  the  presence  of  biliary  stasis  and 
deficiency  of  bile  in  the  intestine  the  absorption  of  fat  is  dimin- 
ished. If  the  stools  be  stirred  in  water,  drops  of  fat  collect  upon 
the  surface  on  standing,  and  if  these  be  examined  microscopically 
innumerable  delicate  needles  of  sodic  or  magnesic  soaps  will  be 
found.  The  stools  retain  their  bilious  color  in  the  presence  of 
jaundice  if  the  obstruction  to  the  flow  of  bile  through  the  intes- 
tine is  not  complete,  or  if  the  icterus  be  of  pleiochromic  or  diffu- 
sive origin.  Jaundiced  persons  are  often  annoyed  by  distressing 
itching  of  the  skin — cutaneous  pruritus — the  existence  of  ^vhich  may 
disclose  itself  to  the  eye  by  the  presence  of  scratch-marks  and 
crusts  upon  the  skin.  The  itching  frequently  occurs  at  night,  and 
deprives  the  patient  of  needed  sleep.  In  all  probability  it  depends 
upon  the  action  of  the  biliary  acids  circulating  in  the  blood  upon 
the  cutaneous  vasomotor  and  sensory  nerves, .  as  some  patients 
maintain  with  positiveness  that  the  sense  of  itching  has  been  pre- 
ceded by  a  sensation  of  coldness  in  the  skin. 

Less  common  cutaneous  alterations  in  association  witli  jaundice  are 
erythema,  urticaria,  xanthelasma. 

Not  rarely  jaundice  is  attended  with  slowing  of  the  action  of  the 
heart  and  of  the  pulse — bradycardia  and  slow  pulse.  These  like- 
"wise  are  attril)utable  to  irritation  of  the  ganglion-cells  of  the  myo- 
cardium by  the  biliary  acids  circulating  in  the  blood.  The  pulse 
has  been  observed  to  be  as  low  as  21  beats  in  the  minute. 

Among  less  common  phenomena  are  disorders  of  vision,  as,  for  instance, 
yelloxo  vision — xanthopsia — the  development  of  which  is  attributed  by  some 
to  nervous  influences,  while  others  explain  its  occurrence  by  infiltration  of 
the  optic  structures  of  the  eye  with  biliary  coloring-matter.  At  times 
hemeralopia  and  nyctalopia  are  observed.  Besides  the  blood  and  the  urine, 
the  biliary  coloring-matter  may  appear  also  in  the  sweat  and  the  milk, 
although  it  is  not  found  in  the  saliva,  the  tears,  and  the  seminal  fluid. 

Jaundiced  patients  complain  frequently  of  anorexia,  a  bitter 
taste,  insomnia,  and  mental  irritability.  The  tongue  is  usually 
coated.  The  duration  of  jaundice  varies  with  the  causes  present 
in  the  individual  case.  Chronic  jaundice  is  usually  attended  with 
progressive  emaciation,  because  the  nutrition  is  impaired  and  inter- 
fered with.  Under  the  same  conditions  disMolution  of  the  blood 
may  occur,  so  that  more  or  less  extensive  and  numerous  hemor- 
rhages may  take  place  into  the  skin  and  the  various  mucous 
membranes,  and  also  into  the  retina.  Occasionally  profound  jaun- 
dice is  attended  with  nervous  manifestations,  which  have  been 
designated  cholemia.  The  patients  become  stupid  and  delirious, 
throw  themselves  restlessly  about  in  bed,  grind  their  teeth,  and  are 
seized  with  clonic  muscular  spasm  in  one  or  more  extremities  or 


JAUNDICE  321 

throughout  the  entire  body.  Death  occurs  quite  frequently  under 
such  conditions.  The  cause  of  cholemia  was  formerly  thought  to 
be  an  intoxication  of  the  central  nervous  system  with  biliary  con- 
stituents— according  to  some  with  biliary  acids,  according  to  others 
with  cholesterin  ;  but  at  present  the  tendency  is  to  adopt  the  view 
that  cholemia  depends  upon  auto-intoxication,  and  that  the  injurious 
substances  consist  in  putrefactive  alkaloids — ptomains — which  are 
generated  in  the  intestine  in  consequence  of  the  deranged  digestion. 

Diagnosis. — The  recognition  of  jaundice  is  easy,  although  the 
clinician  should  never  be  satisfied  with  a  diagnosis  of  jaundice, 
but  in  every  instance  he  should  determine  the  causes  of  this  symp- 
tom. Under  these  circumstances  considerable  difficulty  may  arise, 
which  can  be  overcome  only  by  a  careful  consideration  of  the 
etiology  and  the  alterations  in  individual  organs.  Icteric  discol- 
oration of  the  skin  can  be  readily  recognized  only  by  daylight,  and 
not  at  all  by  the  light  of  a  lamp.  It  can  be  easily  differentiated 
from  the  yellowish  color  of  the  skin  in  brunets,  because  in  the  latter 
the  sclerse  remain  w^hite  and  the  urine  presents  no  change.  The 
skin  and  the  urine  may  present  a  yellow  color  after  the  use  of 
picric  acid  or  santonin,  and  the  urine,  as  in  jaundice,  may  yield 
a  yellow  foam,  but  the  color  of  the  urine  is  a  light  yellow,  and 
the  reaction  for  biliary  coloring-matter  is  wanting.  On  the  other 
hand,  the  urine  acquires  a  reddish  color  on  the  addition  of  potas- 
sium hydroxid. 

Prognosis. — The  prognosis  in  cases  of  jaundice  depends  upon 
the  curability  of  the  causative  conditions. 

Anatomic  Alterations. — In  the  bodies  of  those  dead  of 
jaundice  the  icteric  color,  not  only  of  the  skin  and  the  mucous 
membranes,  but  also  of  almost  all  of  the  tissues  and  organs,  is 
striking,  the  nervous  tissues  alone  remaining  unaffected.  Serous 
effusions  into  the  pleural  cavity,  the  pericardium,  the  peritoneal 
cavity,  and  in  the  meningeal  spaces  present  a  yellowish,  icteric 
hue.  Chicken-fat  clots  in  the  cavities  of  the  heart  likewise  present 
an  icteric  appearance.  The  endocardium  and  the  intima  of  the 
blood-vessels  are  stained  yellow.  The  kidneys  are  characterized 
especially  by  their  icteric  color.  The  epithelial  cells  in  the  con- 
voluted uriniferous  tubules  are  in  a  state  of  more  or  less  marked 
fatty  degeneration,  and  are  often  stained  yellow  by  biliary  coloring- 
matter.  When  jaundice  has  existed  for  a  long  time  the  biliary 
coloring-matter  is  precipitated  in  the  form  of  granules  in  the  epi- 
thelial cells.  Cylindric  collections  of  biliary  coloring-matter  also 
occur  in  the  uriniferous  tubules.  The  liver  is  generally  enlarged,  and 
often  presents  a  deep  yellowish-black  or  greenish-yellow  appear- 
ance. If  the  jaundice  is  dependent  upon  obstruction  to  the  flow 
of  bile  by  occlusion  of  the  biliary  passages,  the  bile-ducts  appear 
dilated,  and  in  places  represent  cystic  enlargements  distended 
with  bile.     Under  such  circumstances  there  may  be  connective- 

21 


322  •  DIGESTIVE  ORGANS 

tissue  hyperplasia  and  cellular  proliferation  around  the  biliary 
passages.  On  microscopic  exaniinatiou  the  liver-cells  are  found 
to  be  saturated  -with  biliary  col(n*ing-matter.  In  eases  of  long 
standing  the  biliary  coloring-matter  is  precipitated  in  the  cells  in 
the  form  of  granules,  and  less  commonly  in  that  of  needles  or 
plates.  Enlargement  of  the  spleen  is  common.  It  is  important 
to  observe  to  what  point  the  biliary  passages  are  stained  yellow, 
for  the  obstruction  to  the  flow  of  bile  must  have  been  seated  at 
the  junction  between  the  portion  containing  and  the  portion  free 
from  bile.  This  point  is  often  not  capable  of  demonstration  in 
the  dead  body.  At  times  microscopic  examination  of  the  liver 
furnishes  for  the  first  the  explanation  for  the  development  of  the 
jaundice.  Thus,  for  instance,  it  has  been  demonstrated  of  the 
jaundice  following  phosphorus-poisoning  that  it  is  dependent  upon 
a  catarrhal  condition  of  the  smaller  intrahepatic  biliary  ducts. 

Treatment. — Although  the  treatment  of  jaundice  should 
always  be  directed  to  the  removal  of  the  causative  factors,  there 
are,  however,  certain  rules  to  be  observed  in  the  presence  of  any 
variety  of  the  condition.  In  connection  with  the  food  it  should 
be  a  fixed  rule  to  interdict  the  use  of  fat  (butter,  fat  meat,  fatty 
sauces,  unskimmed  milk,  yolk  of  egg).  AYeak  coffee  with  milk, 
tea  with  milk,  strained  meat-l)roth,  lean  meat,  good  white  wine, 
alkaline  and  carbonated  waters,  may  be  permitted.  Daily  evacua- 
tion of  the  bowels  should  be  secured.  Rectal  injections  of  water 
at  ordinary  temperature  are  to  be  preferred.  A  single  large  dose 
of  calomel  (0.5 — 7^  grains)  or  of  a  preparation  of  rhubarb  or 
senna  mav  prove  useful.  Patients  of  means  with  chronic  jaundice 
mav  be  sent  to  bathing-resorts,  among  which  especially  Carlsbad, 
Marienbad,  Homburg,  Kissingen,  and  Tarasp  may  be  recom- 
mended. Of  medicaments,  hydrochloric  acid  and  nitric  acid  are 
much  employed,  and  these  in  any  event  exert  a  favorable  influence 
upon  the  stomach,  whose  function  is  generally  affected  : 

R  Solution  of  dilute  hydrochloric  acid,        5.0  :  180.0 

(75  minims  :  6  fluidounces). 
Sirup  of  raspberry,  20.0  (5  fluidraras).— M. 

Dose:  15  c.c.  (1  tablespoonful)  every  two  hours  after  food. 

R  Dilute  hvdrochloric  acid, 

Dilute  nitric  acid,  each,    2.5  (40  minims); 

Sirup  of  raspberry,  20.0  (5  fluidrams) ; 

Distilled  water  sufficient  to  make  200  {^  fluidounces).— M. 
Dose :  15  c.c.  (1  tablespoonful)  every  two  hours. 

For  the  relief  of  the  often  intolerable  itching  of  the  sJcin  warm 
baths  may  be  employed  (28°  R.— ;3o°  C— 95°' R),  followed  by 
the  application  of  a  carbolated  ointment : 

R  Carbolic  acid,  5.0  (75  grains)  ; 

Wool-fat. 

Lard,  each,  25.0  (6  drams).— M. 

For  inunction. 


HYPOSTATIC  LIVER  323 

Application  to  the  skin  of  lemon-juice  and  the  administration 
of  potassium  bromid  internally  (2.0 — 30  grains)  have  also  been 
recommended.  In  order  to  accelerate  the  desquamation  of  the 
icteric  shin  after  recovery  from  jaundice  warm  baths  with  soda 
(100.0 — 3  ounces)  may  be  given.  For  the  relief  of  cholernia 
stimulants  should  be  employed,  as,  for  instance,  camjahorated  oil 
(1.0 — 15  minims — subcutaneously  thrice  daily),  and  active  diuresis 
should  be  induced  by  the  generous  administration  of  tea  and 
milk  in  order  to  eliminate  the  injurious  substances  rapidly  from 
the  body.  If  the  patients  are  unable  to  swallow  on  account  of 
stupor,  rectal  injections  of  tepid  milk  or  physiologic  salt-solution 
(0.75  per  cent.)  should  be  given  or  subcutaneous  infusions  of 
saline  solution. 

HYPOSTATIC  LIVER  (VENOUS  HYPEREMIA  OF  THE 

LIVERj, 

Ktiology. — Hypostasis  of  the  liver  develops  when  the  flow 
of  venous  blood  of  the  liver  from  the  hepatic  veins  into  the  infe- 
rior vena  cava  is  obstructed.  Such  a  condition  occurs  in  asso- 
ciation with  chronic  diseases  of  the  heart  and  of  the  respiratory- 
organs,  and  the  mechanism  generally  consists  in  failure  in  the 
function  of  the  right  ventricle.  As  a  result  a  certain  amount 
of  blood  is  left  in  the  right  ventricle  after  each  systole  of  the 
heart.  In  consequence  the  right  auricle  next  becomes  imper- 
fectly emptied,  then  also  the  superior  and  the  inferior  vena  cava, 
and  thus  are  provided  the  conditions  that  lead  to  hypostasis  of 
the  liver. 

In  rare  instances  hypostasis  of  the  liver  develops  in  consequence  of 
stenosis  of  the  hepatic,  veins.  This  is  dependent  at  times  upon  congenital 
septum-like  obstruction,  at  other  times  upon  acquired  thickening  and  con- 
striction of  the  vessel-wall.  Under  such  circumstances  the  stasis  is  con- 
fined exclusively  to  the  liver  and  the  portal  circulation,  while  in  the  pres- 
ence of  stasis  of  cardiac  origin  the  entire  distribution  of  the  inferior  vena 
cava  is  involved  in  the  stasis. 

Anatomic  Alterations. — Hypostasis  of  the  liver  is  attended 
with  increase  in  size  and  marked  hyperemia,  so  that  the  organ 
often  exhibits  a  reddish-black  color.  On  section  an  oakleaf-like 
or  nutmeg-like  appearance  is  disclosed,  the  darker  portions  cor- 
responding to  the  dilated  central  veins  in  the  individual  lobules 
of  the  liver  distended  with  blood.  The  organ  is  therefore  also 
designated  cyanotic  nutmeg-liver.  On  microscopic  examination 
also  the  dilatation  of  the  central  veins  and  the  efferent  intra- 
lobular capillaries,  and  their  distention  with  blood,  are  conspicu- 
ous. If  the  condition  has  existed  for  some  time,  there  may  readily 
result,  in  consequence  of  the  pressure  exerted  by  the  dilated  blood- 
vessels, atrophy  and  disappearance  of  the  liver-cells,  and  the  atro- 


324  DIGESTIVE  ORGANS 

phic  nutmeg-liver  develops.  Under  such  conditions  also  hyper- 
plasia of  the  connective  tissue  not  rarely  takes  place  around  the 
dilated  vessels.  The  consistence  of  the  liver  at  the  same  time 
increases,  and  in  consequence  of  cicatricial  contraction  of  the 
connective  tissue  the  liver  may  even  undergo  diminution  in  size, 
with  the  formation  of  nodules  upon  its  surface — the  so-called  cir- 
rhotic- n  utiiicr/-liv('i\ 

Symptoms  and  Diagnosis. — If,  as  in  the  majority  of  cases, 
hypostasis  of  the  liver  is  dependent  upon  chronic  disease  of  the 
heart  or  of  the  respiratory  organs,  the  first  manifestation  of  stasis 
is  general  cutaneous  edema  in  the  lower  extremities,  as  the  con- 
sequences of  general  stasis  are  observed  earliest  in  the  dependent 
portions  of  the  body.  Symptoms  of  hypostasis  of  the  kidneys 
(diminution  in  the  amount  of  urine,  which  has  a  high  color  and 
a  high  specific  gravity,  with  a  small  amount  of  albumin)  also 
often  appear  earlier  than  those  of  hypostasis  of  the  liver.  Patients 
with  Itypostasis  of  the  liver  complain  principally  of  a  sense  of 
weight,  of  pressure,  of  constriction,  and  even  of  slight  pains  in 
the  region  of  the  liver.  On  palpation  and  percussion  the  liver  is 
found  enlarged,  and  particularly  Avitli  its  lower  border  projecting 
in  greater  or  lesser  degree  beyond  the  right  costal  margin.  At  the 
same  time  the  consistence  of  the  organ  appears  increased,  although 
its  surface  feels  smooth.  Manipulation  of  the  liver  is  frequently 
attended  -with  tenderness.  Xot  rarely  hypostatic  catarrh  of  the 
biliary  passages  develops,  with  obstruction  and  hypostatic  jaundice. 
The  jaundice  is  commonly  not  pronounced,  and  is  often  confined 
to  the  conjunctivae.  If  at  the  same  time  tiiere  is  cyanosis  of  the 
skin  in  consequence  of  the  stasis,  the  jaundiced  integument  at 
times  acquires  a  slightly  greenish  hue — iderua  viridis.  Exami- 
nation of  the  liver  is  rendered  difficult,  and  sometimes  even  im- 
possible, when  marked  ascites  is  present.  An  attempt  should  then 
be  made  to  determine  the  limits  and  the  consistency  of  the  organ 
by  shock-like  palpation  in  the  region  of  the  liver.  It  is  also 
advisable  under  such  circumstances  to  examine  the  liver  with  the 
patient  in  the  left  lateral  or  in  the  supine  decubitus.  If  the  stasis 
can  be  relieved  and  the  right  ventricle  can  be  strengthened,  it  is 
often  remarkable  in  how  short  a  time  the  enlargement  of  the  liver 
subsides.  If,  however,  the  stasis  has  existed  for  a  considerable 
time  or  has  recurred  frequently,  complete  involution  will  no  longer 
take  place,  obviously  on  account  of  the  hyperplasia  of  the  con- 
nective tissue  of  the  liver.  The  liver,  therefore,  remains  hard 
and  large.  If  ascites  be  present,  it  will  also  prove  obstinate  under 
such  conditions.  In  the  differentiation  of  hypostasis  of  the  liver 
from  other  varieties  of  enlargement  of  tlie  liver  and  from  indura- 
tion of  the  liver  the  demonstration  of  causes  of  hypostasis  is 
imjiortant. 

Prognosis. — The  prognosis  depends  upon  the  possibility  of 


INFLAMMATION  OF  THE  SEROUS  COAT  OF  THE  LIVER.     325 

renioviDg  the  causes  of  stasis.  As  a  rule,  this  is  possible  at  first ; 
but  subsequently  the  heart  becomes  insusceptible  to  the  influence 
of  medicaments,  and  deatli  results  in  consequence  of  excessive 
general  stasis. 

Treatment. — The  principal  remedies  consist  in  heart-tonics, 
particularly  digitalis.  In  general,  the  treatment  is  that  of  weak- 
ness of  the  myocardium  (pp.  23  and  24).  In  the  presence  of 
marked  tension  and  pain  in  the  region  of  the  liver  from  5  to 
10  tcet  cups  should  be  applied. 


INFLAMMATION    OF    THE   SEROUS    COAT  OF    THE 
LIVER  (PERIHEPATITIS). 

Anatomic  Alterations  and  Btiology. — A  distinction  is 
made  between  acute  and  chronic  perihepatitis.  Acute  perihepa- 
titis is  attended  with  the  presence  of  fibrinous  deposits  upon  the 
serous  covering  of  the  liver;  Accumulations  of  pus  also  may 
readily  take  place  between  the  surface  of  the  liver  and  the 
diaphragm,  and  often  the  pus  is  encapsulated  in  several  cavities. 
At  times  the  serosa  of  the  liver  is  detached  from  the  surface  of 
the  organ  by  small  accumulations  of  pus.  Acute  perihepatitis 
occurs  most  commonly  in  association  with  diiFuse  peritonitis.  At 
times  it  attends  diseases  of  the  liver  extending  to  the  serous  cov- 
ering, as,  for  instance,  abscess,  carcinoma,  gumma,  echinococcus. 
Injuries  in  the  region  of  the  liver  are  of  less  common  occurrence. 
AVhether  refrigeratory  (rheumatic)  perihepatitis  occurs  is  at  least 
doubtful.  On  the  other  hand,  acute  perihepatitis  may  result  by 
extension  from  adjacent  disease,  and  it  may  be  superadded  to 
pleurisy  or  pericarditis.  Chronic  perihejxttitis  develops  at  times 
from  an  acute  perihepatitis,  while  in  other  instances  it  occurs  as 
an  independent  disorder.  It  is  characterized  by  thickening  of  the 
serous  covering  of  the  liver  and  by  band-like  or  extensive  adhe- 
sions between  the  surfice  of  the  liver  and  neighboring  structures, 
particularly  the  diapliragm.  At  times  the  thickening  may  attain 
the  extent  of  several  millimeters,  and  appear  white  and  opaque, 
and  cut  almost  like  cartilage.  If  the  liver  is  entirely  surrounded 
bv  a  serosa  thus  altered,  an  appearance  is  created  as  if  the  organ 
were  enclosed  within  a  layer  of  icing,  whence  the  name  mold  or 
cast  of  the  liver.  In  consequence  of  contraction  of  the  thickened 
connective  tissue,  nodules  not  rarely  form  upon  the  surface,  and 
distortion  of  the  organ  results.  Frequently  the  liver  assumes  a 
globular  shape.  Further,  the  connective-tissue  hyperplasia  ex- 
tends here  and  there  into  the  superficial  interlobular  spaces  of  the 
liver.  Syphilis  is  not  an  uncommon  cause  for  chronic  perihepa- 
titis. Hereditary  syphilis  also  at  times  causes  extensive  peri- 
hepatitic  changes  in  children.     At  times  the  disorder  develops  in 


326  DIGESTIVE  ORGANS 

the  course  of  clironle  diseases  of  the  liver,  as,  for  instance,  chronic 
interstitial  hepatitis.  Traumatic  chronic  perihepatitis  occurs  in 
association  witli  constricted  liver  in  the  course  of  the  constriction 
and  in  the  adjacent  tissue.  Chronic  peritonitis  also  may  give  rise 
to  chronic  periiiepatitis. 

Symptoms  and  Diagnosis. — Acute  periiiepatitis  can  l)e 
diagnosed  with  certainty  only  when  a  perihepatitic  friction- 
sound  is  generated  with  the  respiratory  movements  of  the  liver. 
This  may  be  appreciable  only  with  the  stethoscope,  or  it  may  le 
felt  with  the  hand  as  the  creaking  of  new  leather.  It  is  encoun- 
tered most  commonly  over  the  lower  portion  of  the  right  side  of 
the  chest,  although  it  may  be  observed  also  upon  the  lateral  and 
posterior  aspects,  or  it  may  be  present  in  these  situations  and  ab- 
sent anteriorly.  At  times  it  can  be  induced  artificially  by  sliding 
the  abdominal  walls  upon  the  surface  of  the  liver.  Its  duration 
is  susceptible  of  great  variation.  At  times  it  is  observed  for  only 
a  few  minutes,  in  other  instances  for  several  weeks,  now  disap- 
pearing, but  soon  reappearing  suddenly.  Perihepatitic  friction  is 
distinguished  from  pleuritic  friction-sounds  by  the  fact  that  it  ex- 
tends especially  toward  and  may  even  pass  beyond  the  lower  bor- 
der of  tlie  chest.  The  patients  complain  principally  of  pain  in  the 
region  of  the  liver,  which  is  increased  on  deep  inspiration  and  on 
pressure.  On  percussion  it  may  often  be  demonstrated  tliat  the 
respiratory  movements  of  the  liver  are  restricted,  because  the  ]Datients 
involuntarily  avoid  active  respiratory  movement  on  account  of  the 
pain.  Consequently  a  slight  degree  of  hypostatic  jaundice  devel- 
ops at  times,  as  active  respiratory  movement  of  the  liver  favors 
the  discharge  of  bile.  Chronic  perihepatitis  also  is  frequently 
attended  with  palpable  and  audible  friction-phenomena.  Intimate 
adhesions  to  surrounding  structures  prevent  the  respiratory  dis- 
placement of  the  liver.  If  the  hepatic  veins  or  the  inferior  vena 
cava  be  surrounded  and  constricted  in  consequence  of  connective- 
tissue  thickening,  ascites  or  general  stasis  in  the  veins  of  the 
extremities  and  of  the  abdomen  develops.  At  times  stenosis  of  the 
portal  vein  or  of  the  large  biliary  ducts  in  the  hilus  of  the  liver 
results,  and  is  followed  by  incurable  ascites  or  persistent  icterus. 

Prognosis. — The  prognosis  of  acute  perihepatitis  is  favorable 
if  the  causative  conditions  are  not  dangerous.  The  prognosis  of 
chronic  perihepatitis  also  is  usually  not  unfavorable.  Stenosis  of 
the  inferior  vena  cava  and  the  hejiatic  veins,  of  the  portal  vein, 
and  the  large  biliary  ducts  naturally  gives  rise  to  conditions  of 
incurable  venous  stasis  or  to  chronic  jaundice,  which  finally  termi- 
nate fatally  Avith  progressive  asthenia  and  interference  with  the 
movements  of  the  diaphragm. 

Treatment. — If  pain  be  severe,  hot  cataplasms  over  the  liver 
and  cups,  and  even  subcutaneous  injections  of  morphin  may  be  ad- 
vised.    Excessive  ascites   will    require   repeated  puncture   of  the 


SUPPURATIVE  HEPATITIS  327 

abdomen.     Chronic  jaundice  ^\•ill  demand  regulation  of  the  diet 
and  regularity  of  bowel-movement. 

SUPPURATIVE    HEPATITIS. 

l^tiology. — Suppurative  inflammation  of  the  liver  occurs  only 
when  bacteria  capable  of  inducing  inflammation  gain  access  to  the 
organ.  The  demonstration  of  bacteria  will  be  possible  only  in 
recent  accumulations  of  pus,  as  they  undergo  destruction  in  the 
older,  so  that  the  abscess  becomes  sterile.  Streptococcus  pyogenes, 
Staphylococcus  pyogenes  albus  and  aureus,  and  Bacterium  coli 
commune  have  been  found  in  abscesses  of  the  liver. 

In  abscesses  of  the  liver  secondary  to  dysentery  the  amebce.  of  dysentery 
have  been  observed  repeatedly,  although  it  is  doubtful  whether  these  are 
not  rather  accidental  contaminations,  the  suppuration  being  really  induced 
by  pyogenic  cocci.  The  same  statement  is  applicable  to  an  observation  of 
flagellates  in  hepatic  pus. 

Any  of  the  vessels  of  the  liver  may  be  the  portal  of  entry  for  bac- 
teria into  the  organ ;  thus  the  hepatic  artery,  the  portal  vein,  the 
hepatic  veins,  the  biliary  passages,  and  in  the  newborn  the  umbili- 
cal vein.  The  biliary  passages  and  the  portal  vein  are  the  most 
common  channels.  The  portal  vein  is  a  frequent  portal  of  entry 
for  bacteria  into  the  liver  in  connection  with  all  pyemic  abscesses 
of  the  liver.  These  develop  when  inflammatory  ])rocesses  occur 
in  any  organ  connected  with  the  distribution  of  the  portal  vein, 
and  from  which  exciting  agents  of  inflammation  can  enter  the 
portal  vein  and  its  intrahepatic  ramifications.  Among  primary 
inflammatory  processes  may  be  mentioned  ulceration  of  the  intes- 
tinal mucous  membrane,  in  connection  with  which  endemic  tropi- 
cal dysentery  particularly  has  an  unfavorable  reputation,  opera- 
tions upon  and  inflammation  of  the  rectum,  the  uterus,  the  ovaries, 
and  the  tubes,  the  testicles,  ulceration  of  the  vermiform  appendix 
and  the  stomach,  the  spleen,  the  pancreas,  etc.  Suppurative 
pylephlebitis  may  also  be  responsible  for  secondary  suppuration 
in  the  liver.  Suppuration  in  the  liver  by  way  of  the  hilkiry  pas- 
sages occurs  especially  in  the  sequence  of  gall-stones,  in  connection 
with  which  the  Bacterium  coli  commune  appears  to  be  the  exciting 
agent  of  the  purulent  process  with  especial  frequency.  Less  com- 
mon] v  parasites  in  the  biliary  passages  may  be  the  starting-point 
for  suppuration  in  the  liver. 

The  hepat'iG  artery  is  the  medium  for  infection  of  the  liver 
particularly  in  the  presence  of  ulcerative  endocarditis,  and  at 
times  also  in  association  with  pulmonary  gangrene  and  putrid  bron- 
chitis, as  the  thrombi,  containing  bacteria,  invade  the  distribution 
of  the  aorta,  and  then  that  of  the  hepatic  artery,  finally  to  be- 
come obstructed  in  the  arterial  capillaries  of  the  liver,  and  from 
this   point  to  excite   inflammation    of   the   liver.      Bacteria    can 


32«  DIGESTIVE  ORGANS 

enter  the  liver  through  the  Jiepafic  vci)is  only  by  passing  in  a 
direction  contrary  to  that  of  the  blood-stream.  Experimental 
investigation  has  shown  that  corpuscular  elements  may  pass  down- 
ward in  the  inferior  vena  cava,  in  opposition  to  the  blood-stream 
toward  the  heart,  and  enter  the  he])atie  veins,  and  this  phenomenon 
has  been  accepted  in  explanation  of  cases  of  su[)})uration  of  the 
liver  in  which  hepatic  abscesses  have  developed  in  the  sequence 
of  inflammation  and  suppuration  of  the  cranium  and  at  the 
periphery  of  the  body.  At  the  present  day  such  an  assumption 
is,  in  our  opinion,  no  longer  necessary,  as  bacteria  can,  without 
difficulty,  if  they  have  gained  entrance  through  the  superior  vena 
cava  to  the  right  auricle,  the  right  ventricle,  and  the  pulmonary 
artery,  migrate  through  the  pulmonary  capillaries,  and  pene- 
trate the  pulmonary  veins,  the  left  side  of  the  heart,  the  aorta, 
and  the  hepatic  artery.  Only  if  the  question  arose  as  to  the  dissem- 
ination of  coarse,  solid  particles  "would  scarcely  any  other  explana- 
tion be  conceivable  than  the  entrance  from  the  superior  into  the 
inferior  vena  cava  and  thence  into  the  hepatic  veins  and  their  rami- 
fications. In  the  newborn,  infection  of  the  liver  sometimes  occurs 
through  the  umbilical  wound  or  through  the  intermediation  of  the 
umbilical  vein.  Infection  of  the  umbilical  wound,  in  case  the  mother 
be  suffering  from  childbed-fever  (puerperal  septicemia),  or  infection 
of  the  umbilical  wound  from  want  of  cleanliness  in  treatment,  is 
the  causative  factor.  It  thus  appears  that  suppurative  inflamma- 
tion of  the  liver  may  occur  at  any  period  of  life.  At  times  abscess 
of  the  liver  results  from  injuries  to  the  organ,  even  of  a  blunt  char- 
acter. In  other  instances  it  develops  in  the  course  of  infectious 
diseases,  as,  for  instance,  malaria.  It  is  especially  widespread  in 
tlie  Orient,  in  consequence  of  the  frequent  occurrence  of  endemic 
dvsentery.  There  are,  however,  cases  in  which  no  cause  can  be 
demonstrated — so-called  spontaneous  abscess  of  tJic  liver.  An  espe- 
cial group  of  cases  of  abscess  of  the  liver  is  constituted  by  those 
varieties  that  develop  in  consequence  of  the  svppvration  of  tuber- 
cles, carcinornata,  or  cchinococci  of  the  liver.  Abscess  of  the  liver 
occurs  most  commonly  in  men. 

Anatomic  Alterations. — A  distinction  must  be  made  be- 
tween si)i(jlc  and  multiple  absce.ss  of  the  liver.  INIultiple  abscesses 
occur  in  the  liver  particularly  in  relation  with  pyemic  influences. 
The  size  of  a  liver-abscess  is  susceptible  of  great  variation.  At 
times  the  collection  of  pus  is  scarcely  visible,  while  at  other  times 
it  may  be  so  enormous  as  to  occupy  almost  an  entire  lobe.  In 
accordance  with  the  situation  of  the  accumulation  of  pus  a  dis- 
tinction can  be  made  between  superficial  (peripheral)  and  deejy 
(central)  abscesses.  Accumulations  of  pus  of  some  standing  are 
usually  surrounded  by  a  connective-tissue  capsule,  whereas  more 
recent  accumulations  are  in  direct  contact  with  the  tissue  of  the 
liver — encapsulated  and  non-encapsulated  abscesses  of  the  liver.     The 


SUPPURATIVE  HEPATITIS  329 

pus  in  many  instances  resembles  ordinary  greenish  and  creamy 
pus,  altliough  at  times  it  acquires  a  viscid  consistency  or,  from 
being  stained  by  bile,  an  appearance  of  wine-lees.  At  times, 
also,  it  possesses  putrid  qualities.  The  liver  is  as  a  rule  enlarged, 
and  almost  always  there  is  likewise  enlargement  of  the  spleen.  If 
the  abscesses  of  the  liver  are  of  pyemic  origin,  similar  collections 
of  pus  may  be  present  in  numerous  other  organs. 

On  microscopic  examination  necrosis  of  the  liver-cells  and  the  adjacent 
tissue  will  be  found  in  the  structures  surrounding  the  pyogenic  bacteria. 
Next  there  collect  about  these  small  necrotic  areas  round  cells  that  have 
probably  wandered  principally  out  of  the  blood-vessels,  but  have  resulted 
in  part  also  by  multiplication  of  the  liver-cells  and  other  cells.  A  sub- 
miliary  or  miliary  abscess  is  thus  formed.  By  the  confluence  of  adjacent 
small  abscesses  larger  collections  of  pus  are  formed.  Even  large  abscesses 
not  rarely  coalesce  with  one  another,  as  indicated  by  their  multilocular  form. 

Symptoms  and  Diagnosis. — In  order  to  be  recognized  with 
certainty  during  life,  abscesses  of  the  liver  must  have  attained  a 
certain  size  and  be  situated  at  the  surface  of  the  organ.  Deeply 
seated  collections  of  pus  are  either  entirely  inaccessible  to  recog- 
nition or  can  at  best  be  suspected  with  some  degree  of  probability. 
The  demonstration  of  a  fluctuating  prominence  upon  the  surface  of 
the  liver  is  decisive  in  the  diagnosis.  Although  unilocular  echino- 
coccus  and  soft  carcinomata  or  sarcomata  of  the  liver  are  also 
attended  with  fluctuating  prominences,  septic  constitutional  mani- 
festations are  wanting  under  these  conditions.  Naturally  an 
abscess  of  the  liver  will  be  accessible  to  the  palpating  fingers  only 
when  it  is  in  contact  with  the  abdominal  wall,  and  but  rarely  will 
it  be  possible  to  feel  it  in  the  intercostal  spaces.  If  it  has  devel- 
oped at  the  summit  of  the  convexity  of  the  liver,  it  can  be  recog- 
nized only  from  the  presence  of  dulness  on  percussion,  which 
abruptly  interrupts  the  course  of  the  upper  border  of  the  liver 
and  forms  a  convex  prominence  toward  the  pleural  cavity.  Under 
such  conditions  there  may  be  danger  of  confounding  an  abscess 
of  the  liver  with  an  encapsulated  pleural  empyema  or  with  a  sub- 
phrenic abscess  or  with  an  echinococcus-cyst.  It  will  then  be  neces- 
sary to  take  into  consideration  the  mode  of  development  of  the 
disorder  (cough,  pleural  pain,  previous  gastric  or  intestinal  disturb- 
ance), and  to  make  exploratory  puncture  of  the  doubtful  accumu- 
lation of  pus.  A  fecal  odor  of  the  pus  is  suggestive  of  a  subphrenic 
abscess,  while  in  the  presence  of  an  echinococcus-cyst  a  clear  fluid 
free  from  albumin  would  be  expected.  At  times  an  abscess  of  the 
liver  is  so  closely  applied  to  the  abdominal  wall  that  it  may  be 
mistaken  for  an  abscess  of  the  abdominal  wall.  The  important 
point  in  differential  diagnosis  would  then  be  whether  the  accumu- 
lation of  pus  moves  with  the  respiratory  movement,  and  this  is 
indicative  of  abscess  of  the  liver. 

The  development  of  an  abscess  of  the  liver  is  usually  attended  with 


330  DIGESTIVE  ORGANS 

raost  indefinite  symptoms.  The  patients  complain  frequently  of 
pain  in  the  liver,  which  at  times  extends  to  the  right  shoulder  and 
tlie  right  arm;  also,  tiic  liver  is  frequently  tender  on  pressure,  in 
part  throughout  an  extensive  area  and  in  part  to  an  especially 
marked  degree  in  a  circumscribed  area  corresponding  to  the  situa- 
tion of  the  abscess.  Enlargement  of  the  liver  then  usually  takes 
place  progressively.  Frequently  jaundice  develops,  but  this  is  by 
no  means  a  constant  symptom.  Enlargement  of  the  spleen  is  almost 
always  demonstrable  (infection-spleenj.  In  addition  there  are 
signs  of  general  sepsis :  irregular  febgle  movement,  generally 
remitting  or  hectic  fever,  chills  preceding  the  elevation  of  tem- 
perature, sweats,  loss  of  appetite,  progressive  anemia,  and  exhaus- 
tion. Should  permanent  relief  not  be  afforded,  death  may  result 
from  asthenia.  At  times,  however,  alarming  coinjjlications  may 
arise  in  consequence  of  rupture  of  a  liver-abscess.  Rupture  into 
the  peritoneal  cavity  is  particularly  dangerous,  as  this  is  generally 
soon  followed  by  fatal  perforative  peritonitis.  The  abscess  may, 
however,  rupture  also  into  any  of  the  adjacent  organs  (pleural 
cavity,  pericardium,  lungs,  stomach,  intestines,  urinary  passages), 
and  even  through  the  external  integument,  and  at  times  a  natural 
cure  of  the  abscess  has  then  been  observed  to  take  place.  A 
serious  occurrence  is  rupture  of  the  pus  into  the  hepatic  veins,  the 
portal  vein,  or  the  interior  vena  cava,  as  fatal  hemorrhage  or 
general  septicemia  may  result. 

The  duration  of  an  abscess  of  the  litter  may  extend  over  a  few 
weeks,  several  months,  and  a  number  of  years  (up  to  fifteen),  so  that 
a  distinction  is  made  bet^\  een  acute,  subacute,  and  chronic  abscess  of 
the  liver.  In  addition  to  rupture,  natural  cure  of  an  abscess  of  the 
liver  may  take  place  in  consequence  of  inspissatiou  and  calcification, 
and  in  the  case  of  small  collections  of  pus,  of  cicatrization ;  Ijut  these 
occurrences  are  extremely  rare.  Small  and  deeply  situated  abscesses 
of  the  liver  cannot  be  recognized  during  life.  In  some  instances 
scarcely  more  than  the  clinical  picture  of  sepiicopjiemia  is  devel- 
oped, without  alterations  in  the  liver  itself.  At  times  chills  occur 
at  such  regular  intervals  that  intermittent  fever  may  be  suspected, 
but  malarial  ])lasmodia  cannot  be  found  in  the  blood.  Also,  if 
jaundice  should  develop  the  diagnosis  cannot  be  estalilished  beyond 
the  point  of  jirobability,  as  jaundice  may  occur  in  conjunction  with 
pyemic  conditions,  even  apart  from  su]ipuration  of  the  liver. 

Progtiosis  and  Treatment. — The  prognosis  of  abscess  of 
the  liver  has  been  materially  improved  since  time  is  no  longer 
wasted  with  internal  remedies,  but  as  soon  as  the  condition  is 
discovered  it  is  subjected  to  siu'gical  treatment.  Naturally,  the 
prognosis  depends  besides  upon  the  nature  of  the  causative  factors. 
The  outlook  for  pyemic  abscesses  is  grave,  because  they  are  often 
multiple,  and  are,  therefore,  less  readily  susceptible  to  surgical 
intervention,  and,  besides,  because  the  pyemic  constitutional  state 


CHRONIC  INTERSTITIAL  HEPATITIS  331 

is  in  itself  a  most  serious  condition.  An  abscess  of  the  liver  should 
be  opened  as  soon  as  the  diagnosis  is  made  with  certainty,  in  order 
to  avoid  the  dangers  of  rupture.  Internal  remedies  are  incapable 
of  causing  absorption  of  pus  in  the  liver.  A  nutritious  diet  and 
alcohol  in  generous  quantities  may  be  advised  for  the  septico- 
pyemic general  condition. 

CHRONIC  INTERSTITIAL  HEPATITIS  (CIRRHOSIS  OF 

THE  LIVER), 

!]^tiology. — Chronic  interstitial  inflammation  of  the  liver  is 
also  known  as  contracted  liver  and  cirrhosis  of  the  liver,  but  both  of 
these  designations  are  inadequate,  because  chronic  interstitial  in- 
flammation of  the  liver  does  not  always  give  rise  to  diminution 
in  the  size  or  to  contraction,  and  because,  also,  the  diseased  organ 
does  not  always  present  a  light-yellow  color,  for  xippo;;  means  yel- 
low. The  causes  for  chronic  interstitial  inflammation  of  the  liver 
consist  in  chemic  poisons,  bacterial  poisons  (toxins),  or  anomalous 
metabolic  products.  It  has  been  known  for  a  long  time  that 
excessive  indulgence  in  alcohol  is  the  most  common  cause  for 
the  disorder.  Spirit-drinkers  are  particularly  exposed  to  danger, 
and  the  condition  has  been  spoken  of  as  spir it-drinkers'  or  drunk- 
ards' liver,  and  the  less  dilute  and  the  more  abundantly  spirit  is 
drunk  the  more  readily  does  the  disease  develop.  Those  who 
partake  liberally  of  food  in  conjunction  with  indulgence  in  spirit 
may  the  longer  escape  the  evil  effects  of  their  habits.  Cirrhosis 
of  the  liver  occurs  much  less  commonly  in  those  who  indulge  in 
wine  and  beer. 

Whether  other  irritating  articles  of  food  also  are  capable  of  inducing 
interstitial  inflammation  of  the  liver  is  not  definitely  known.  It  has  been 
stated  that  such  a  result  may  be  brought  about  by  excessive  use  of  curry. 
In  animals  hyperplasia  of  the  interstitial  connective  tissue  of  the  liver  has 
been  induced  by  long-continued  administration  of  phosphorus.  I  have 
observed  a  similar  condition  in  a  girl  after  phosphorus-poisoning. 

Cirrhosis  of  the  liver  develops  occasionally  in  the  sequence  of 
infectious  disease,  as,  for  instance,  after  hereditary  or  acquired  syph- 
ilis, pulmonary  tuberculosis,  miliary  tuberculosis,  and  malaria. 
At  times  the  disease  is  associated  with  alterations  in  the  biliary- 
passages  (calculi,  stenosis  or  occlusion),  and  under  such  circum- 
stances infectious  factors  must  be  taken  into  consideration.  Pos- 
sibly the  toxins  of  the  colon-bacterium  play  an  important  part,  as 
this  organism,  under  the  conditions  named,  is  readily  capable  of 
gaining  access  to  the  biliary  passages.  Among  the  metabolic  dis- 
orders that  may  give  rise  to  chronic  interstitial  inflammation  of 
the  liver  diabetes  and  c/out  may  be  named.  Some  varieties  of 
chronic  interstitial  hepatitis  are  dependent  upon  arteriosclerotiG 
alterations  in  the  hepaiic  artery  and  its  intrahepatic  ramifications, 


332  DIGESTIVE  ORGANS 

and  in  the  same  way  as  in  the  kidneys  also  senile  contraction 
of  the  liver  may  be  recognized.  Among  all  of  the  causative 
factors  excessive  indulgence  in  alcohol  is  the  most  important, 
and  this  explains  the  fact  that  the  disease  is  most  common  in  ineu 
in  the  lower  icalhs  of  life,  and  that  it  is  more  prevalent  in  some 
countries  than  in  others.  Experience,  unfortunately,  demonstrates 
that  at  times  children  also  are  encouraged  by  their  parents  to 
drink  spirit,  with  the  result  that  cirrhosis  of  the  liver  develops. 

Anatomic  Alterations. — Chronic  interstitial  inflammation 
of  the  liver  may  appear  in  various  anatomic  forms,  and  accord- 
ingly several  varieties  of  the  disease  have  been  distinguished. 
All,  however,  agree  in  the  fact  that  the  interlobular  connective 
tissue  throughout  the  entire  liver  has  undergone  diffuse  and  ab- 
normal hyperplasia.  Accordingly  that  variety  of  circumscribed 
connective-tissue  hyperplasia  that  takes  place  about  abscesses, 
new-growths,  and  echinococci  in  the  liver,  and  forms  a  capsule  for 
these,  does  not  belong  in  this  category.  Likewise  the  connective- 
tissue  hyperplasia  that  develops  in  connection  with  conditions  of 
chronic  venous  stasis  and  involves  at  first  and  principally  the 
dilated  intralobular  blood-capillaries  is  not  included.  Probably 
every  liver  in  which  the  connective  tissue  has  undergone  morbid 
hyperplasia  appears  at  first  enlarged.  Subsequently  cicatricial 
contraction  of  the  connective  tissue  often  takes  place,  and  as  a 
result  the  contracted  liver  or  atrophic  cirrhosis  of  the  liver  develops. 
If,  on  the  contrary,  the  liver  remains  persistently  enlarged,  the 
condition  is  one  of  hypertrophic  cirrhosis  of  the  liver.  The  drunk- 
ard's liver  is  usually  one  of  atrophic  cirrhosis,  but  there  are  cases 
in  which,  although  the  disease  has  been  of  long  duration,  the  liver 
remains  enlarged. 

We  shall  first  describe  fully  alcoholic  cin'hosis  of  the  liver. 
In  the  developed  stage  of  the  disease  the  liver  is  diminished 
in  size,  particularly  its  left  lobe,  and  the  designation  contracted 
liver  is  therefore  appropriate  for  this  condition.  The  organ 
is  light  yellow  or  light  yellowish-brown  in  color,  whence  the 
designation  cirrhosis  of  the  liver.  The  surface  of  the  organ 
exhibits  numerous  irregularities  and  nodules,  in  consequence  of 
which  the  disease  has  acquired  the  name  of  granular  atrophi/  of 
the  liver.  The  nodules  vary  in  size  between  that  of  a  poppy- 
seed  and  that  of  a  cherry.  The  depressions  are  represented  by  a 
grayish,  almost  translucent,  tissue,  and  they  result  from  contraction 
of  the  newly  formed  connective  tissue,  while  the  projecting  nodules 
consist  of  liver-tissue,  which  in  places  presents  an  almost  ochre- 
vellow  color  from  saturation  of  the  liver-cells  with  biliary  coloring- 
matter.  The  capsule  of  the  liver  often  appears  thickened  in  cir- 
cumscribed or  in  extensive  areas,  and  it  is  at  times  adherent  to 
adjacent  organs,  particularly  the  diaphragm.  Also,  on  section  of 
the  organ  the  nodular  appearance  of  the  surface  is  conspicuous,  and 


CHRONIC  INTERSTITIAL  HEPATITIS  333 

likewise  here,  as  upon  the  surface  of  the  liver,  grayish,  depressed 
areas,  consisting  of  newly  formed  connective  tissue,  are  visible,  and 
between  which  light-yellow  or  ochre-yellow  colored  liver-tissue 
projects.  At  times,  owing  to  the  dense  hyperplastic  connective 
tissue  present,  the  liver  has  acquired  such  an  indurated  consistency 
that  on  section  with  a  knife  a  creaking  sound  is  audible,  aud  ac- 
cordingly the  designation  hardening  or  induration  of  the  liver  seems 
appropriate.  In  some  cases  thrombosis  of  the  jwrtcd  vein  develops. 
The  abdominal  cavity  almost  always  contains  transudate.  The 
spleen  is  generally  enlarged  and  hard ;  the  mucous  membrane  of 
the  stomach  and  intestines  presents  the  appearances  of  chronic 
catarrh. 

On  microscopic  examination  of  the  liver  the  increase  in  the  interlobular 
connective  tissue  is  conspicuous.  Generally  several  lobules  are  surrounded 
by  a  broad  band  of  connective  tissue,  and  for  this  reason  alcoholic  cirrhosis 
has  also  been  designated  multilobular  cirrhosis  of  the  liver.  The  connective 
tissue  often  presents  the  appearance  of  cicatricial  tissue  deficient  in  cells, 
although  in  more  recent  areas  an  abundance  of  young  cells  are  present,  and 
these  are  particularly  numerous  close  to  the  peripheral  liver-cells.  The 
intrahepatic  branches  of  the  pjortal  vein  are  obstructed  or  occluded  in  numer- 
ous places  in  consequence  of  obliterative  endophlebitis.  It  is  assumed  that 
the  vascular  changes  are  dependent  upon  the  connective-tissue  hyperjilasia, 
and  for  this  reason  alcoholic  cirrhosis  of  the  liver  is  designated  hho  portal 
cirrhosis.  The  liver-cells  themselves  are  often  in  an  advanced  state  of  fatty 
degeneration,  and  this  is  probably  due  in  part  also  to  the  action  of  the 
alcohol,  while  in  other  places  they  have  undergone  atrojjhy  in  consequence 
of  the  pressure  exerted  by  the  newly  formed  connective  tissue.  Often  they 
are  stained  deeply  yellow  with  biliary  coloring-matter.  The  ascites  that 
almost  constantly  attends  alcoholic  cirrhosis  of  the  liver,  the  hypostatic 
catarrh  of  the  gastro-intestinal  membrane,  and  the  enlargement  of  the 
spleen  are  considered  as  consequences  of  stasis  in  the  portal  circulation 
dependent  upon  obstruction  of  the  intrahepatic  branches  of  the  portal 
vein. 

An  hypertrophic  biliary  or  monolobular  cirrhosis  of  the  liver 
has  recently  been  distinguished  from  the  alcoholic  form  of  chronic 
interstitial  inflammation  of  the  liver  first  accurately  described  by 
Laennec,  and  therefore  designated  Laennec's  cirrhosis  of  the  liver. 
The  former  is  characterized  by  aljnormal  enlargement  of  the 
liver,  with  a  smooth  surface  and  a  bilious  and  dark-green  color. 
The  bands  of  connective  tissue  may  attain  quite  considerable  pro- 
portions, and  the  liver  may  then  be  traversed  by  grayish  bands, 
which  at  times  may  be  confounded  with  neoplastic  infiltration. 
The  biliary  passages  frequently  are  abnormally  dilated  and  exces- 
sively distended  with  bile.  The  weight  of  the  liver  may  become 
twice  or  thrice  the  normal.  On  microscopic  examination  the 
hyperplastic  connective  tissue  will  be  found  generally  surround- 
ing individual  lobules  of  the  liver  (monolobular  cirrhosis),  and  to 
be  the  seat  of  marked  increase  and  ramification  of  the  smaller 
biliary  passages,  from  which  the  connective-tissue  hyperplasia 
appears  to  have  arisen  {biliary  cirrhosis  of  the  liver).     The  newly 


334  DIGESTIVE  ORGANS 

formed  connective  tissue  exhibits  no  tendency  to  undergo  cica- 
tricial contraction,  and  therefore  the  liver  does  not  become  reduced 
in  size. 

l^yphilitic  cirrhosis  of  the  liver  has  been  designated  also 
monocellular  cirrhosis  of  the  liver,  because  the  connective-tissue 
hyperplasia  occurs  about  individual  liver-cells  and  causes  their 
destruction  by  pressure.  The  liver  is  often  greatly  changed  in 
shape,  one  or  more  portions  of  the  organ  becoming  detached  from 
the  main  body  by  bridges  of  connective  tissue,  and  the  liver  is 
thus  converted  into  a  multilobulated  organ — syphilitic-  lobulated 
liver. 

Little  is  as  yet  kuo^Yn  -with  regard  to  senile  or  arteriosclerotic 
ciiThosis  of  the  liver,  which  resembles  the  alcoholic  variety  of  the 
disease  and  is  attended  Avith  contraction  after  previous  enlarge- 
ment. ]\Iicroseopically  the  extensive  obliterative  endarteritis  in 
the  intrahej^atic  branches  of  the  hepatic  artery  is  a  conspicuous 
feature. 

Symptoms  and  Diagnosis. — The  several  anatomic  varie- 
ties of  cirrhosis  of  the  liver  correspond  also  with  various  clinical 
pictures,  and  we  shall  describe  these  with  the  qualification  that 
typical  conditions  will  be  considered.  The  distinctive  symptoms 
of  alcoholic  cirrhosis  of  the  liver  are  usually  preceded  by  manifes- 
tations of  chronic  gastro-intestinal  catarrh,  which  likewise  is 
dependent  upon  excessive  indulgence  in  alcohol.  The  patients 
become  more  and  more  emaciated,  lose  their  appetite,  and  acquire 
a  peculiar  grayish-yellow  color  of  the  skin.  The  sclerse  generally 
are  distinctly  jaundiced.  ^Marked  icteric  discoloration  of  the 
skin  and  mucous  membranes  does  not  occur,  as  a  rule.  In  some 
cases  disagreeable  sensations  of  tension,  of  pressure,  and  even  of 
pain  in  the  region  of  the  liver  occur,  while  in  others  attention 
is  first  attracted  to  the  disease  by  increase  in  girth  in  consequence 
of  accumulation  of  fluid  in  the  abdominal  cavity.  If  oppor- 
tunity be  afforded  to  examine  the  liver  at  an  early  stage  of  the 
disease,  it  will  be  found  to  be  enlarged,  with  its  lower  border  at 
the  level  of  the  umbilicus,  and  even  lower.  At  the  same  time 
the  hardness  of  the  organ  is  notable,  and  this  may  be  distinctly 
recognized  by  palpation  of  the  lower  margin  of  the  liver.  Gradu- 
ally the  liver  undergoes  progressive  diminution  in  size,  and  its 
lower  border  Mill  be  found  above  the  right  costal  margin.  If  the 
abdominal  walls  are  thin  and  deficient  in  fat,  the  trained  hand 
may  succeed  in  detecting  nodular  irregularities  upon  the  surface 
of  the  liver.  The  examination  of  the  liver  is  sometimes  attended 
with  insurmountable  difficulty  from  the  accumulation  of  fluid  in 
the  abdominal  cavity,  causing  distention  of  the  abdominal  walls 
and  displacing  the  liver  upward  into  the  concavity  of  the 
diaphragm.  At  times  the  information  desired  can  be  gained 
through  percussion  and  palpation  to  a  certain  degree  by  practis- 


CHRONIC  INTERSTITIAL  HEPATITIS  335 

in^  shock-like  palpation  in  the  dorsal  decubitus,  or  percussion  and 
palpation  with  the  patient  occupying  the  left  lateral  decubitus  or 
the  prone  position. 

Dropsy  of  the  abdominal  cavity — ascites — is  quite  a  constant 
symptom  of  alcoholic  cirrhosis  of  the  liver,  and  is  dependent  upon 
stenosis  and  partial  occlusion  of  intrahepatic  branches  of  tlie 
portal  vein,  and  the  resulting  increase  of  blood-pressure  in  the 
trunk  of  this  vein.  The  abdominal  walls  are  not  rarely  distended 
to  the  utmost,  and  the  heart  and  the  lower  margins  of  the  lungs, 
together  with  the  diaphragm,  may  be  greatly  displaced  upward. 
The  umbilicus  not  rarely  forms  a  marked  projection  forward,  and 
in  transmitted  light  appears  translucent  because  the  umbilical 
hernia  contains  serous  fluid  from  the  abdominal  cavity.  Not 
rarely  points  of  rupture  in  the  cutis  are  observed  upon  the  lower 
half  of  the  abdomen  in  the  form  of  strige.  Often  excessively  dis-. 
tended  and  markedly  tortuous  cutaneous  veins  in  the  abdominal 
wall  attract  attention.  Usually  the  trunk  of  each  inferior  epigas- 
tric vein  ascends  from  the  middle  of  Poupart's  ligament,  and 
sends  off  various  ramifications  at  the  level  of  the  umbilicus. 
These  unite  with  branches  of  the  superior  epigastric  veins,  which 
generally  disappear  at  the  level  of  the  nipple  and  in  the  direction 
of  the  axillary  cavity.  Obviously  these  conditions  are  dependent 
upon  the  venous  collateral  circulation  that  develops  because  the 
ascitic  fluid  rests  upon  and  compresses  the  inferior  vena  cava. 

An  uncommon  variety  of  venous  collateral  circulation  in  cases  of  cir- 
rhosis of  the  liver  is  known  as  the  caput  Medusce — cirsomphalos.  This  con- 
sists in  the  presence  of  greatly  dilated  veins  surrounding  the  umbilicus, 
and  constituting  a  sort  of  cavernoma.  The  vessels  are  branches  of  the  epi- 
gastric veins,  which  have  entered  into  anastomosis  with  the  patulous  umbil- 
ical vein  in  the  round  ligament  of  the  liver. 

In  contradistinction  from  hypostatic  ascites,  it  is  distinctive 
of  the  ascites  of  alcoholic  cirrhosis  of  the  liver  that  the  extrem- 
ities are  free  from  cutaneous  edema.  Only  when  the  ascites,  by 
reason  of  its  weight,  causes  considerable  stenosis  of  the  vena  cava 
will  hypostatic  edema  develop  ;  but  this  is  characterized  by  the 
fact  that  it  is  slight  as  compared  with  that  of  marked  ascites. 
At  times  cachectic  edema  of  the  skin,  or  edema  of  the  extremities 
on  one  side,  develops  in  consequence  of  marantic  thrombosis  of  the 
femoral  vein.  The  spleen  is  almost  always  enlarged,  although 
excessive  ascites  often  prevents  recognition  of  this  condition. 
Recently  attention  has  been  called  to  the  fact  that  the  old  view, 
according  to  which  the  enlargement  of  the  spleen  is  due  to  stasis 
in  the  portal  vein,  appears  not  to  be  correct,  because  enlargement 
of  the  spleen  at  times  occurs  so  early  that  it  is  more  probably 
correct  that  the  enlargement  of  the  spleen  and  that  of  the  liver 
are  dependent  upon  identical  causes.  If  the  excessive  indulgence 
in  alcohol  has  already  given  rise  to  chronic  gastro-intestinal  catarrh, 


336  DIGESTIVE  ORGANS 

this  becomes  materially  aggravated  in  consequence  of  portal  cir- 
rhosis of  the  liver,  because  tiie  obstruction  and  occlusion  of  the 
intrahepatic  branches  of  the  portal  vein  give  rise  to  stasis  in  the 
veins  of  the  stomach  and  the  intestine.  At  times  hemorrhoids 
develop.  If  the  stasis  becomes  excessive,  there  may  be  extensive 
hemorriiagcs  in  the  mucous  membrane  of  the  stomach,  and  vomit- 
ing of  blood — hematemesis.  At  times,  however,  blood  that  is 
vomited  may  come  from  varicose  dilatations  of  the  veins  in  the 
lotcer  portion  of  the  esophagus.  Death  from  hemorrhage  may 
take  place  within  a  short  time  from  uncontrollable  bleeding. 
The  duration  of  alcoholic  cirrhosis  of  the  liver  is,  as  a  rule,  more 
than  a  year  (up  to  live  years).  But  rarely  is  an  acute  course  of 
a  few  weeks  observed.  The  course  of  the  disease  is  usually  afeb- 
rile. At  times,  however,  febrile  movement  occurs,  the  cause  of 
which  is  unknown — hepatic  fever.  In  some  cases  death  results 
from  aspjhyxia  and  cardiac  parcdysis  if  the  accumulation  of  fluid 
in  the  abdominal  cavity  has  become  so  considerable  that  the  lungs 
and  the  heart  are  unduly  displaced  upward.  Other  patients  die 
amid  signs  of  progressive  asthenia.  Under  such  conditions  symp- 
toms of  dissolution  of  the  blood  appear  upon  the  skin  and  the 
mucous  membranes.  The  occurrence  of  fatal  hemorrhage  from 
the  dilated  esophageal  veins  has  already  been  mentioned. 

The  diagnosis  of  alcoholic  cirrhosis  of  the  liver  is  easy  if  the 
three  main  symptoms — a  small,  hard,  nodular  liver,  enlargement 
of  the  spleen,  and  ascites — are  present,  particularly  if  the  patient  is 
admittedly  a  spirit-drinker  and  presents  a  salloAV,  slightly  icteric 
tint  of  the  skin.  Should,  however,  marked  ascites  prevent  examina- 
tion of  the  liver  and  the  spleen,  the  condition  may  lie  confounded 
with  thrombosis  of  the  portal  vein,  and  tuberculous,  carcinomatous,  and 
chronic-serous  peritonitis.  Under  .such  conditions  the  most  reliable 
procedure  is  to  remove  the  ascites  by  puncture  of  the  abdom- 
inal cavity,  because  subsequently  the  liver  and  the  spleen  become 
accessible  often  with  surjirising  distinctness  immediately  after  the 
puncture,  and  are  susceptible  of  examination.  At  times,  natur- 
ally, the  liver  remains  in  the  concavity  of  the  diapliragm  in  spite 
of  abdominal  puncture,  generally  in  consequence  of  perihepatitic 
adhesions  to  the  diaphragm.  It  should  then  not  be  forgotten 
that  thrombosis  of  the  portal  vein  usually  develops  in  the  sequence 
of  inflammatory  and  ulcerative  processes  in  the  stomach,  intestine, 
and  gcnito-urinary  a])paratus  ;  that  carcinomatous  inflammation 
of  the  peritoneum  occurs  in  advanced  life,  and  is  associated  with 
cachexia ;  and  that  tuberculous  peritonitis  is  generally  secondary 
to  tuberculosis  of  the  lungs,  intestines,  or  mesenteric  glands,  and 
is  usually  associated  with  pain  and  febrile  movement,  but  without 
icterus.  At  times  pericardial  adhesions,  with  myocardial  weak- 
ness and  stasis,  particularly  in  the  veins  <>f  the  peritoneum,  con- 
stitute a  source  of  great  diagnostic  difficulty.     The  decision  will 


CHRONIC  INTERSTITIAL  HEPATITIS  337 

then  depend  principally  upon  the  demonstration  of  the  previous 
presence  or  absence  of  pericarditis.  The  typical  picture  of  hyper- 
trophic or  biliary  cirrhosis  of  the  liver  is  produced  by  that  variety 
of  the  disease  which  has  been  designated  also  hypertrophic  cirrho- 
sis of  the  liver  toith  jaundice.  In  this  disorder  the  liver  is  greatly 
enlarged,  and  its  lower  border  often  extends  considerably  below 
the  level  of  the  umbilicus.  Also  its  upper  border  may  be  dis- 
placed upward.  At  the  same  time  the  organ  is  characterized  by 
increased  resistance  and  hardness,  although  its  surface  appears 
smooth,  and  the  liver  does  not  undergo  diminution  in  size.  The 
spleen  also  usually  exhibits  considerable  enlargement.  Ascites-- 
is  not  present,  but  on  the  other  hand  jaundice  is  marked.  The 
patients  complain  principally  of  a  sense  of  pressure  and  of  tension 
in  the  region  of  the  liver  and  of  derangement  of  gastro-intestinal 
activity.  The  disease  usually  pursues  a  slow  course,  and  at  times 
may  persist  for  more  than  five  years.  Progressive  emaciation,  at 
times  also  cholemic  manifestations,  usually  lead  to  death. 

In  two  cases  I  have  observed  the  clinical  picture  of  hypertrophic  cir- 
rhosis of  the  liver  with  jaundice  in  which  post-mortem  examination  dis- 
closed the  existence  of  pseudofeukemia.  Enlargement  of  the  liver  and  of 
the  spleen  had  resulted  from  pseudoleukemic  new-growths,  and  the  profound 
icterus  from  the  pressure  exerted  by  enlarged  lymph-glands  upon  the  hepatic 
ducts  in  the  transverse  fissure.  Between  portal  and  biliary  cirrhosis  of  the 
liver  there  are  various  relations  and  gradations,  so  that  a  whole  series  of 
Varieties  of  cirrhosis  of  the  liver  has  been  described.  The  following  sche- 
matic enumeration  is  presented : 

I.  Alcoholic  or  portal  cirrhosis  of  the  liver. 

a.  With  atrophy  of  the  liver,  ascites,  and  enlargement  of  the  spleen ; 

b.  With  hypertrophy  of  the  liver,  ascites,  and  enlargement  of  the 
spleen ; 

c.  With  jaundice. 

II.  Hypertrophic  or  biliary  cirrhosis  of  the  liver,  with  jaundice. 

III.  Biliary  cirrhosis  of  the  liver,  ivith  consecutive  atrophy. 

a.  With  enlargement  of  the  spleen  ; 

b.  Without  enlargement  of  the  spleen. 

In  one  of  my  patients  a  monolobular  form  of  cirrhosis  of  the  liver  was 
suddenly  superadded  to  a  preexisting  multilobular  cirrhosis  and  caused 
death  in  the  second  week  of  the  disease,  being  attended  with  enlargement 
of  the  spleen,  but  without  jaundice  and  ascites;  and  in  another,  in  wliich 
death  resulted  from  cholemia,  there  Avas  found  on  macroscopic  examination 
the  typical  appearances  of  hypertrophic  portal  cirrhosis  of  the  liver,  while 
microscopic  examination  disclosed  a  most  bpautiful  example  of  monolobu- 
lar cirrhosis  of  the  liver.  Ascites  M'as  not  present.  The  classifications  sug- 
gested therefore  scarcely  indicate  more  than  that  every  case  of  cirrhosis  of 
the  liver  may  possess  peculiarities  of  its  own,  and  should  be  carefully  ex- 
amined. Upon  what  these  peculiarities  depend  has,  however,  not  yet  been 
explained. 

Syphilitic  cirrhosis  of  the  liver  is  characterized  especially  by  the 
constricting  off  of  individual  portions  of  the  liver.  It  may  be 
readily  confounded  with  constricted  liver  and  with  tumors  of  the 

■    22 


338  DIGESTIVE  ORGANS 

liver.  Little  is  known  with  regard  to  senile  or  arte r to-sclerotic  cir- 
rhosis of  the  liver.  It  develops  insidiously  in  elderly  persons  who 
perhaps  may  always  have  passed  temperate  lives,  the  liver  being 
large  and  hard,  and  subsequently  undergoing  reduction  in  size. 
Ascites  occurs  and  death  results  from  excessive  asthenia. 

Prognosis. — The  prognosis  of  cirrhosis  of  the  liver  is  unfa- 
vorable, tor  there  is  no  remedy  capable  of  causing  disappearance 
of  the  hyperplastic  connective  tissue,  and,  besides,  the  disease  ex- 
hibits an  undeniable  tendency  to  progress.  As  a  rule,  the  patients 
are  at  so  advanced  a  stage  of  the  disease  when  they  come  under 
observation  for  treatment  that  the  outlook  for  therapeutic  success 
is  small.  Nevertheless,  isolated  observations  have  been  made  in 
wliich  it  has  been  possible  to  check  the  progress  of  the  disease, 
and  to  relieve  distressing  symptoms  permanently,  particularly  the 
ascites. 

Treatment. — In  the  treatment  causal  therapy  plays  an  im- 
portant part.  The  patients  should  be  ^veaned  from  the  use  of 
alcohol,  or  if  syphilis  be  the  etiologic  factor,  potassium  iodid 
(5.0  :  200 — 75  grains  :  6|-  fluidounces  ;  15  c.c. — 1  tablespoonful — 
thrice  daily),  mercurous  chlorid  (0.5 — 1\  grains ;  1  such  powder 
thrice  weekly),  or  mercurial  ointment  (5.0 — 75  grains — to  be  used 
by  inunction  daily  for  25  or  30  days)  should  be  prescribed.  In 
cases  of  arterio-sclerotic  cirrhosis  of  the  liver  the  employment 
of  potassium  iodid  may  be  recommended.  Among  ssrmptomatic 
remedies  potassium  iodid  and  mercurous  chlorid  occupy  first  place. 
A  milk-diet  should  be  observed  (1  or  2  quarts  of  thoroughly  l)oiled 
milk  in  small  amounts  at  intervals  of  from  one-quarter  to  one- 
half  an  hoiu'  throughout  the  day),  as  milk  is  an  easily  digestible 
and  nutritious  article  of  food,  and  it  also  stimulates  diuresis. 
Local  treatment  will  be  required  with  especial  frequency  for  the 
excessive  ascitic  accumuhdion.  Generally  little  can  be  accom- 
plished with  diuretics,  laxatives,  and  diaphoretics.  The  most 
reliable  measure  is  abdominal  puncture.  As  a  rule,  the  fluid  natu- 
rallv  soon  reaccumulates,  but  there  is  no  objection  to  repeating  the 
puncture  from  time  to  time.  It  is  properly  becoming  more  com- 
monly the  practice  not  to  reserve  puncture  as  a  last  resort,  but 
to  employ  it  early  in  order  to  avert  threatening  asphyxia.  At 
times  reaccumulation  of  the  fluid  does  not  take  place  after  punc- 
ture, and  recovery  ensues.  Courses  of  treatment  at  springs  should 
be  prescribed  only  when  ascites  is  abseut  or  inconsiderable,  so  that 
the  patient  can  move  about.  Carlsbad,  Marienbad,  Homburg, 
Kissingen,  and  Tarasp  especially  may  be  recommended. 

ACUTE  YELLOW  ATROPHY  OF  THE  LIVER, 

Btiology.  —  Acute  yellow  atrophy  of  the  liver  is  an  exceedingly 
rare  disease,  and  is  attended  with  rapid  fatty  degeneration  of  the 


ACUTE   YELLOW  ATROPHY  OF  THE  LIVER  339 

liver-cells,  with  their  disintegration  and  absorption,  so  that  within  a 
few  days  the  liver  becomes  greatly  diminished  in  size.  The  dis- 
ease develops  generally  under  the  influence  of  bacterial  poisons 
(toxins)  and  perhaps  also  of  putrefactive  alkaloids  (ptomains), 
although  little  of  a  definite  nature  is  known  in  this  connection. 
It  has  been  maintained  further  that  certain  chemic  poisons  (phos- 
phorus, fungous  poisons)  may  cause  acute  yellow  atrophy  of  the 
liver,  but  under  such  circumstances  there  is  probably  resemblance 
rather  than  identity  in  the  anatomic  and  clinical  pictures.  At  times 
acute  yellow  atrophy  of  the  liver  develops  in  the  sequence  of 
infectious  diseases,  as,  for  instance,  typhoid  fever,  pharyngeal 
diphtheria,  enteritis,  and  syphilis.  At  other  times  the  disease 
occurs  as  a  complication  of  other  diseases  of  the  liver,  as,  for  in- 
stance, cirrhosis  and  fatty  liver.  Occasionally  small  endemics  of 
acute  yellow  atrophy  of  the  li.ver  have  been  observed  in  barracks, 
so  that  the  suggestion  of  an  independent  infectious  disease  has 
been  raised.  It  is  known  that  the  disease  occurs  with  relative 
frequency  during  pregnancy,  and  with  particular  frequency  between 
the  fifth  and  the  eighth  month,  and  less  commonly  in  association 
with  parturition.  Under  such  circumstances  ptomains  may  be 
the  exciting  agents.  Often  a  definite  cause  cannot  be  demon- 
strated— cryptogenetic  atrophy  of  the  liver.  Occasionally  fright, 
emotional  disturbances  of  other  kind,  and  alcoholism  are  assigned 
as  causes.  Experience  has  shown  that  acute  yellow  atrophy  of  the 
liver  occurs  more  commonly  in  women  than  in  men.  Although  the 
disease  is  most  common  at  the  vigorous  period  of  life  (from  25  to 
45),  on  the  other  hand  cases  have  been  observed  also  in  children 
and  the  aged. 

Anatomic  Alterations. — On  opening  the  abdominal  cavity 
the  liver  is  often  not  at  all  visible  from  having  fallen  back  toward 
the  vertebral  column,  and  being  covered  in  front  by  loops  of  intes- 
tine. The  organ  has  often  lost  more  than  half  in  size  and  weight. 
The  capsule  of  the  liver,  therefore,  is  wrinkled.  The  consistence 
of  the  oro^an  is  diminished,  so  that  it  can  almost  be  shaken  to  and 
fro.  On  section  the  liver  presents  a  more  or  less  marked  ochre- 
yellow  color.  In  addition  areas  stained  red  are  present,  resulting 
from  the  ochre-yellow  areas.  Red  markings  are  observed  particu- 
larly in  the  left  lobe  of  the  liver,  in  wdiich  the  disease  is  prone  to 
begin. 

On  microscopiG  examination  attention  is  attracted  particularly 
by  the  marked  fatty  degeneration  of  the  liver-cells.  The  cells 
undergo  disintegration,  the  masses  of  fat  are  partially  absorbed, 
and  eventually  there  remains  a  striated  empty  structure  free  from 
liver-cells.  The  blood-vessels  also  undergo  fatty  degeneration. 
The  interlobular  biliary  passages  stand  out  with  marked  distinct- 
ness, and  appear  hyperplastic.  Cellular  proliferation  and  round- 
cell  accumulation  also  take  place  in  the  interlobular  connective 


340  DIGESTIVE  ORGANS 

tissue,  and  cirrhosis  of  the  liver  has  been  observed  to  develop  in 
the  sequence  of  acute  yellow  atrophy.  At  times,  but  by  no  means 
constantly,  bacteria  have  been  found  in  the  liver  (Streptococcus 
pyogenes,  Staphylococcus  ])yogcne.s  albus,  pneumouiacoccus,  Bacte- 
rium coli  commune).  If  the  liver  has  been  exposed  to  the  air  for 
a  Vvhile,  a  frost-like  deposit  at  times  takes  place  upon  its  sur- 
face, and  this  is  found  upon  microscopic  examination  to  consist  of 
needles  of  tyrosin  and  spheres  of  leucin.  In  all  probability  acute 
yellow  atrophy  of  the  liver  consists  in  a  degenerative  process 
involving  the  liver-cells,  and  to  which  secondarily  inflammatory 
alterations  (proliferation  of  the  biliary  passages,  connective-tissue 
hyperplasia)  are  superadded.  The  remaining  organs  are  generally 
characterized  by  their  marked  icteric  hue.  In  addition,  extrava- 
sations of  blood  occur  in  the  viscera.  Usually  the  glandular  cells 
of  the  stomach,  the  intestine,  the  pancreas,  the  convoluted  urinary 
tubules,  often  also  the  muscle-fibers  of  the  myocardium  and  of 
the  voluntary  muscles,  are  in  a  state  of  fatty  degeneration.  The 
spleen  and  the  portal  and  retroperitoneal  lymph-glands  are  enlarged 
and  softened. 

Symptoms,  Diagnosis,  and  Prognosis. — Acute  yellow 
atrophy  of  the  liver  often  sets  in  with  prodromes,  consisting  in 
symptoms  of  gastro-intestinal  derangement.  Then  icteric  discolor- 
ation of  the  skin  and  of  the  mucous  membranes  takes  place,  and  this 
attains  the  highest  possible  degree  of  intensity  within  a  short  time. 
Soon  symptoms  are  superadded  of  a  condition  that  is  designated 
cholemia,  and  which  has  recently  been  attributed  to  auto-intoxica- 
tion with  abnormal  metabolic  products.  Consciousness  becomes 
more  and  more  obscured,  delirium  develops,  and  the  patients  groan 
and  often  throw  themselves  about  restlessly  in  bed,  and  from  time 
to  time  exhibit  clonic  muscular  contractions  in  individual  extrem- 
ities or  in  all  of  the  muscles.  Often  symptoms  of  blood-dissolution 
further  appear,  and  there  may  be  hemorrhages  beneath  the  skin 
and  the  various  mucous  membranes.  Amid  progressive  loss  of 
consciousness  the  disease  generally  terminates  fatally  in  the  second 
week,  although  at  times  it  may  be  protracted  for  from  six  to  four- 
teen weeks. 

In  the  diagnosis  of  acute  yellow  atrophy  of  the  liver  the  changes 
in  the  liver  and  in  the  urine  are  particularly  important.  On  per- 
cussion, and  to  a  certain  degree  also  on  palpation,  the  liver  will  be 
found  from  day  to  day  to  be  growing  smaller  in  size.  The  dulness 
yielded  by  the  left  lobe  disappears  earliest,  and  eventually  the 
entire  area  of  hepatic  dulness  may  be  reduced  to  a  narrow  band. 
The  liver-dulness  may  even  be  wholly  wanting,  and  be  replaced  by 
an  area  yielding  a  tympanitic  note.  The  diminution  in  the  area 
of  liver-dulness  progresses  gradually  from  below  upward.  Pressure 
over  the  liver  is  in  conspicuous  degree  painful.  Diminution  in  the 
size  of  the  liver  may  be  simulated  by  the  presence  of  intestine — 


ACUTE   YELLOW  ATROPHY  OF  THE  LIVER  341 

as,  for  instance,  the  transverse  colon  greatly  distended  with  gas — 
between  the  surface  of  the  liver  and  the  abdominal  and  thoracic 
walls ;  but  generally  such  a  condition  is  only  a  transient  one,  so 
that  within  a  short  time  the  liver-dulness  is  completely  restored. 
Besides,  the  liver-dulness  can  frequently  be  elicited  by  pressing  the 
plexiraeter  firmly  upon  the  abdominal  wall,  thus  flattening  the 
transverse  colon  upon  the  surface  of  the  liver.  Also,  in  the  pres- 
ence of  free  perforative  peritonitis  disappearance  of  liver-dulness 
takes  place  when  the  gas  thnt  has  escaped  from  the  stomach  or  the 
intestine  into  the  abdominal  cavity  insinuates  itself  between  the 
liver  and  the  thoracic  and  abdominal  walls,  but  such  a  condition 
develops  suddenly,  and  is,  or  at  least  may  be,  unattended  with 
icterus,  while  peritonitic  pain,  abdominal  distention,  and  the  like, 
predominate. 

The  urine  is  usually  passed  in  small  amounts,  possesses  a  deep- 
brown,  icteric  hue,  and  generally  contains  albumin,  fibrinous  tube- 
casts,  epithelial  cells  from  the  uriniferous  tubules  and  the  bladder, 
and  round  cells.  Of  particular  importance  is  the  occurrence  of 
needles  of  tyrosin  in  the  urinary  sediment,  and  which  usually  lie 
together  in  sheaf-like  arrangement,  and  of  spheres  of  leucin,  several 
of  which  are  often  coherent,  and  which  are  characterized  by  their 
double  contour.  Usually  both  of  these  substances  are  precipitated 
spontaneously.  Should  this  not  be  the  case,  they  can  be  precipi- 
tated by  adding  acetic  acid  to  a  drop  of  urine  upon  a  slide,  and 
permitting  evaporation  to  take  place.  It  may  be  remarked  inci- 
dentally that  leucin  and  tyrosin  occur  in  the  urinary  sediment 
also  in  association  with  other  severe  varieties  of  jaundice — as,  for 
instance,  following  phosphorus-poisoning — and  at  times  also  in  the 
course  of  severe  infectious  diseases  (small-pox).  The  amount  of 
urea  in  the  urine  will  be  found  diminished.  Of  abnormal  urinary 
constituents,  sarcolactic  acid  has  further  been  isolated.  All  of  these 
facts  indicate  that  the  metabolism  is  profoundly  altered  in  cases  of 
acute  yellow  atrophy  of  the  liver.  The  disease  is  generally  unat- 
tended with  fever,  and  almost  invariably  terminates  fatally  with 
progressive  asthenia  and  loss  of  consciousness.  The  prognosis  is 
therefore  hopeless. 

Treatment. — Causal  treatment  is  applicable  only  when  syph- 
ilis is  an  etiologic  factor,  and  under  such  conditions  inunctions  of 
mercurial  ointment  (5.0 — 75  grains)  may  be  employed,  and  j^otas- 
sium  iodid  (5.0  :  200 — 75  grains  :  6  J  fluidounces  ;  15  c.c. — a  table- 
spoonful — thrice  daily)  administered.  The  symptomatic  treatment 
consists  in  the  employment  of  stimulants,  as,  for  instance  : 

R  Camphorated  oil,  10.0  (2^  fluidrams). 

Dose :  1  c.c.  (15  minims)  subcutaneously  thrice  daily. 

The  administration  of  from  1  to  2  quarts  of  boiled  milk  daily 
is  advisable  in  order  to  increase  the  secretion  of  urine,  and  thus 


o42  DIGESTIVE  ORGANS 

hasten  the  elimination  of  possible  toxic  metabolic  products  from 
the  body.  It  may  also  be  advantageous  to  stimulate  the  secretion 
of  urine  by  permitting  500  c.c.  (1  pint)  of  lukewarm  physiologic 
salt-solution  (0.7o  jxt  cent.)  to  flow  into  the  rectum  or  beneath  the 
skin  several  times  daily. 

FATTY  OR  ADIPOSE  LIVER, 

Ktiology. — Fatty  liver  is  only  of  subordinate  clinical  sig- 
nificance. A  distinction  must  be  made  between  cachectic,  toxic, 
infectious  fatty  liver,  and  that  due  to  over-eating.  Fatty  liver  due 
to  over-eating  occurs  in  association  with  obesity,  and  develops 
usually  in  persons  who  eat  a  great  deal,  partake  excessively  of 
carbohydrates  and  of  alcoholics,  and  indulge  insufficiently  in  phys- 
ical exercise.  Cachectic  fatty  liver  develops  in  the  sequence  of 
loss  of  blood  or  of  discharges  (protracted  suppuration)  and  debili- 
tating diseases  (pulmonary  tuberculosis,  carcinoma,  chlorosis,  per- 
nicious anemia,  leukemia,  etc.).  Toxic  fatty  liver  occurs  in  the 
train  of  certain  intoxications,  among  which  poisoning  with  phos- 
phorus, arsenic,  and  mercury  may  be  particularly  mentioned. 
Infectious  fatty  liver  is  that  variety  that  develops  not  rarely  in  the 
sequence  of  acute  infections  diseases.  Fatty  liver  occurs  further  in 
association  with  venous  stasis  in  the  form  of  the  fatty  nutmeg-liver, 
and  more  especially  locally  in  connection  with  diseases  of  the  liver 
in  the  neighborhood  of  carcinomatous  abscesses  and  cirrhosis  of 
the  liver.  A  variety  of  physiologic  fatty  liver  occurs  in  infants. 
It  is  a  form  of  fatty  liver  due  to  over-feeding,  and  is  dependent 
upon  the  use  of  milk  containing  much  sugar  in  conjunction  with 
insufficient  bodily  activity. 

Anatomic  Alterations. — In  cases  of  well-developed  fatty 
liver  the  organ  is  enlarged  and  its  margins  blunt.  It  is  light 
gray  or  yellowish  gray  in  color.  On  section  of  the  liver  a  fatty 
deposit  adheres  to  the  blade  of  the  knife.  On  microscopic  exami- 
nation the  liver-cells  are  found  filled  with  large  and  small  fiit- 
globules.  In  addition  some  of  them  not  rarely  contain  consider- 
able biliary  coloring-matter.  A  distinction  has  lieen  made  between 
fatty  infiltration  and  fatty  degeneration  of  the  liver,  accordingly  as 
the  fat  in  the  liver-cells  has  been  deposited  through  the  inter- 
mediation of  the  blood  or  has  developed  in  the  liver-cells  them- 
selves from  disintegration  of  their  proto])lasm.  Prolxdily  the 
fatty  liver  due  to  over-feeding  is  a  variety  of  fatty  infiltration  ; 
while  the  cachectic,  toxic,  and  infectious  forms,  are,  on  the  contrary, 
varieties  of  fatty  degeneration.  The  view  that  fiitty  infiltration 
and  fatty  degeneration  are  distinguishable  from  each  other  by  the 
fact  that  in  cases  of  the  former  the  liver-cells  are  filled  with  large 
fat-globules,  while  in  cases  of  the  latter,  on  the  contrary,  the  liver- 
cells  are  filled  with   numerous  small  and  minute  fat-globules,  is 


AMYLOID  LIVER  343 

not  correct.  It  has  been  pointed  out  that  the  diiferentiation 
between  the  two  conditions  can  be  made  by  chemic  means, 
inasmuch  as  in  the  presence  of  fatty  infiltration  the  amount  of 
water  in  the  liver  is  reduced  (from  70  to  50  per  cent.),  because 
the  fat  has  displaced  the  water  of  the  liver-cells ;  while  in  the 
presence  of  fatty  degeneration  the  amount  of  water  remains  un- 
changed. Should  fatty  liver  be  an  associated  manifestation  of 
general  obesity,  unusually  large  amounts  of  fat  are  found  also 
in  other  organs  and  structures  (subcutaneous  connective  tissue, 
epicardium,   mesentery,  epiploic  appendices). 

Symptoms,  Diagnosis,  and  Prognosis. — Patients  with 
fatty  liver  due  to  over-eating  not  rarely  complain  of  a  sense  of 
tension  and  of  constriction  in  the  region  of  the  liver,  and  on  pal- 
pation and  percussion  this  organ  will  be  found  enlarged,  resistant, 
smooth,  witli  blunt  borders,  and  at  times  also  tender  on  pressure. 
The  remaining  symptoms  of  general  obesity  will  generally  indi- 
cate that  the  manifestations  just  mentioned  are  dependent  upon 
fatty  infiltration  of  the  liver.  To  what  extent  digestion  and 
metabolism  are  thereby  deranged  is  not  definitely  known.  The 
prognosis  depends  upon  whether  the  general  obesity  can  be  cor- 
rected or  not.  Cachectic,  toxic,  and  infectious  fatty  liver  may  be 
wholly  unattended  with  symptoms. 

Treatment. — The  treatment  of  fatty  liver  consists  in  the 
treatment  of  the  fundamental  disorder,  as,  for  instance,  of  that 
variet}"  due  to  over-eating,  in  strict  regulation  of  the  diet. 


AMYLOID  LIVER. 

Ktiology. — Amvloid  degeneration  of  the  liver  may  develop 
as  a  result  of  wasting  discharges  and  cacliectic  states  of  all  kinds, 
as,  for  instance,  protracted  suppuration,  particularly  of  bones  and 
joints,  of  the  kidneys  and  the  pelvis,  pleural  empyema,  chronic 
diarrhea,  pulmonary  tuberculosis,  malarial  and  syphilitic  cachexia. 
In  rare  instances  it  is  impossible  to  ascertain  the  cause,  so  that 
the  disease  gives  the  impression  of  being  an  independent  disorder. 
The  condition  occurs  at  all  periods  of  life,  and  in  children  partic- 
ularly in  the  sequence  of  scrofulous — thus  actually  tuberculous — 
suppuration  of  the  lymphatic  glands,  bones,  or  joints. 

Anatomic  Alterations. — In  cases  of  well-developed  amyloid 
degeneration  the  liver  is  large,  smooth,  and  hard — almost  as  if 
frozen.  Its  weight  may  be  increased  threefold.  On  section  the 
margins  exhibit  an  almost  translucent  aspect,  and  upon  the  cut 
surface  the  liver-substance  can  be  scraped  with  the  knife  as  if  the 
organ  were  frozen.  If  tincture  of  iodin,  or,  still  better,  Lugol's 
solution  (pure  iodin,  0.5 — 7^  grains ;  potassium  iodid,  5.0 — 75 
grains;  distilled  water,  200.0 — 6 J  fluidounces),  be  poured  upon 


344  DIGESTIVE  ORGANS 

the    cut   surface,    the    liver   becomes    stained    dark    brown    or 
mahogany-brown  in  the  amyloid  areas. 

On  viicroscopic  examination  of  the  liver  the  portions  involved 
in  amyloid  degeneration  can  be  recognized  from  their  clear,  waxy 
luster.  They  appear  swollen  and  structureless,  but,  above  all, 
they  yield  the  amyloid  reaction,  being  stained  brown  with  Lugol's 
solution.  If  the  sections  are  then  placed  in  a  watch-glass  contain- 
ing dilute  sulphuric  acid,  they  assume  a  bluish  or  bluish-violet 
tint.  Methyl-violet  gives  the  areas  involved  in  amyloid  degenera- 
tion a  bright-red  tint,  and  they  are  thus  sharply  differentiated 
from  the  adjacent  healthy  tissue  stained  blue. 

Careful  histologic  examination  discloses  that  the  walls  of  the  blood- 
vessels are  first  involved  in  the  process  of  amyloid  degeneration,  and  pri- 
marily the  walls  of  the  hepatic  arteries,  subsequently  those  of  the  inter- 
lobular capillaries  and  the  branches  of  the  portal  vein.  The  liver-cells 
generally  remain  exempt,  and  according  to  some  observers  permanently 
so.  Chemic  examination  of  tlie  amyloid  material  discloses  that  it  contains 
nitrogen,  and  is  a  proteid  substance.  Th&  source  of  this  abnormal  meta- 
bolic product  is  unknown.  In  all  probability  the  amyloid  substance  is 
generated  locally,  for  not  rarely  in  the  application  of  the  amyloid  test 
appearances  are  encountered  in  which  a  gradual  transition  in  color  is 
observed  to  take  place  from  healthy  to  amyloid  tissue.  Some  observers, 
however,  assume  that  the  amyloid  substance  is  brought  to  the  liver  from 
without. 

If  the  amyloid  degeneration  of  the  liver  is  not  well  devel- 
oped, it  can  be  recognized  only  with  the  aid  of  the  reactions 
mentioned.  Almost  always  other  organs  will  also  be  found 
involved  in  the  degenerative  process,  particularly  the  spleen,  the 
adrenal  bodies,  the  kidneys,  and  the  raucous  membrane  of  the 
intestine. 

Symptoms,  Diagnosis,  and  Prognosis. — Amyloid  de- 
generation of  the  liver  will  be  susceptible  of  diagnosis  only  when 
the  liver  is  large,  hard,  and  smooth ;  if  the  condition  has  been 
preceded  by  diseases  that  experience  has  shown  are  frequently 
followed  by  amyloid  degeneration,  and  if  enlargement  and  indu- 
ration of  the  spleen,  edema  of  the  skin,  and  marked  albuminuria 
and  diarrhea  indicate  simultaneous  amyloid  degeneration  of  the 
spleen,  the  kidneys,  and  the  intestine.  Amyloid  liver  is  not 
attended  with  jaundice  unless  the  biliary  passages  be  obstructed 
by  enlarged  lymphatic  glands  in  the  transverse  fissure.  The 
patients  are  usually  pallid  in  consequence  of  the  conditions  that 
are  responsible  for  the  amyloid  disease.  Recovery  can  scarcely 
be  expected.  Death  occurs  most  commonly  from  progressive 
exhaustion. 

Treatment. — In  the  presence  of  amyloid  disease  preparations 
of  iron,  and  particularly  iron  iodid,  are  generally  prescribed, 
although  these  probably  exert  a  useful  influence  upon  the  accom- 
panying anemia  rather  than  ujiou  the  amyloid  condition.     In  a 


CARCINOMA   OF  THE  LIVER  345 

prophylactic  way  it  is  important  to  suppress  chronic  suppuration, 
diarrhea,  and  wasting  discharges  of  all  kinds  as  rapidly  as  possible. 

CARCINOMA  OF  THE  LIVER» 

Htiology. — Carcinoma  of  the  liver  is  an  extremely  common 
disorder.  Almost  invariably  the  condition  is  one  of  secondary 
carcinoma.  Cases  of  primary  carcinoma  of  the  liver  are  exceed- 
ingly rare.  Most  commonly  secondary  carcinoma  of  the  liver 
develops  in  connection  with  carcinoma  of  the  stomach,  the  new- 
growth  extending  directly  from  the  stomach  to  the  liver.  Fre- 
quently, however,  portions  of  the  new-growth  are  conveyed  from 
the  stomach  to. the  liver  as  emboli  through  the  blood-vessels,  and 
thus  give  rise  to  secondary  carcinoma  in  the  liver.  In  addition 
to  the  stomach,  the  uterus,  the  rectum,  the  esophagus,  and  the 
mammary  gland  particularly  are  often  the  seat  of  primary  carci- 
noma, which  is  often  followed  by  secondary  invasion  of  the  liver. 
It  should  be  pointed  out,  further,  that  secondary  carcinoma  of 
the  liver  develops  at  times  in  the  sequence  of  carcinoma,  of  the 
gall-hladder.  Often  biliary  calculi  are  found  in  the  gall-bladder, 
so  that  it  is  reasonable  to  believe  that  these  may  act  as  the  excit- 
ing cause  of  the  new-growth  in  the  gall-bladder.  Naturally,  also, 
they  may  have  developed  subsequently  in  the  diseased  gall-blad- 
der. Carcinoma  of  the  liver  occurs  more  commonly  in  women  than 
in  men.  It  usually  develops  after  the  fortieth  year  of  life,  and 
rarely  earlier. 

Anatomic  Alterations. — Carcinoma  of  the  liver  occurs  in 
two  varieties — namely,  circumscribed  and  infiltrating.  Circum- 
scribed cai^cinoma  forms  well-defined  nodules  that  range  in  size 
from  being  scarcely  visible  to  that  of  a  man's  head.  The  number 
of  nodules  varies  greatly.  At  times  the  liver  is  so  largely  occupied 
by  them  that  but  little  normal  hepatic  tissue  is  left.  At  the  same 
time  the  size  and  the  weight  of  the  organ  may  reach  more  than 
six  times  the  normal.  Carcinomatous  nodules  situated  at  the 
surface  of  the  liver  often  exhibit  a  depression  or  so-called  umbili- 
cation.  On  section  carcinomatous  nodules  usually  present  a  juicy, 
whitish,  or  yellowish-white  medullary  structure,  from  which  car- 
cinomatous juice  or  milk  can  be  scraped  with  a  knife.  At  times 
carcinomatous  nodules  are  conspicuous  for  an  abundance  of  ves- 
sels distended  with  blood,  so  that  they  present  a  reddish  mottled 
appearance  ;  blood-lakes  at  times  form  in  consequence  of  rupture 
of  l)lood-vessels.  Carcinomatous  nodules  may  acquire  a  grayish 
or  slaty  color  from  the  presence  of  pigment  in  large  amount,  and 
the  condition  is  then  designated  pigmentary  carcinoma.  As  in 
other  organs,  also  in  the  liver,  a  distinction  is  made  between 
fibrous  carcinoma  (scirrhus),  medullary  carcinoma,  and  colloid 
carcinoma  (alveolar  carcinoma),  accordingly  as  the  new-growth 


346  DIGESTIVE   OlKiANS 

contains  much  or  little  fluid  or  cavities  filled  with  gelatinous  or 
isinglass-like  material. 

On  rnici-oscopic  examination  the  carcinoma  is  found  to  consist  of  masses 
of  epithelioid  cells  with  large  nuclei  separated  from  one  another  by  a  con- 
nective-tissue framework.  These  cells  originate  in  part  from  the  epithelial 
cells  of  the  biliary  passages,  in  part  from  the  liver-cells. 

The  tissue  of  an  infiltrating  carcinoma  of  the  liver  involves 
the  interlobular  connective  tissue  without  sharp  limitation,  so  that 
unless  microscopic  examination  be  made  confusion  with  cirrhosis 
of  the  liver  is  possible.  This  variety  of  carcinoma  occurs  much 
less  commonly  than  nodular  carcinoma. 

Symptoms  and  Diagnosis. — In  the  diagnosis  of  carcinoma 
of  the  liver  the  demonstration  of  globular  projections  from  the  sur- 
face of  the  liver  is  almost  of  decisive  significance.  Such  a  condi- 
tion is  naturally  possible  only  when  the  new-growths  are  situated 
upon  the  surface  of  the  liver.  Carcinomata  situated  in  the  central 
portions  of  the  liver  are  not  accessible  to  diagnosis.  Under  favor- 
able conditions  they  may  at  best  be  suspected  from  the  fact  that 
the  liver  on  palpation  and  percussion  exhibits  deep  tenderness  in 
circumscribed  areas.  As  a  rule,  the  carcinomatous  projections 
from  the  surface  of  the  liver  can  be  detected  only  liy  palpation, 
and  but  rarely  can  they  also  be  seen  if  the  abdominal  walls  are 
thin  and  deficient  in  fat.  At  times  a  depression  or  umbilication 
can  be  felt  upon  the  surface  of  the  growths,  and  in  exceptional 
instances  I  have  even  seen  this.  The  neoplastic  nodules  are  often 
exceedinglv  tender  on  palpation  and  on  percussion.  At  times  they 
are  so  soft  as  to  exhibit  fluctuation.  Over  highly  vascular  car- 
cinomata cardiac-systolic  vascular  murmurs  may  be  audible.  Of 
diagnostic  significance  is  the  respiratory  mobility  that  the  nodules 
exhibit  together  with  the  organ  in  which  they  are  seated.  Only 
when  the  liver  has  become  greatly  increased  in  size  will  the  vigor 
of  the  diaphragm  be  insufficient  to  transmit  the  respiratory  move- 
ment to  the  liver.  With  a  liver  the  seat  of  extensive  carcinoma- 
tous degeneration,  not  alone  may  the  upper  boundary  of  dulness 
begin  unusually  high,  but  also  the  lower  boundary  may  extend 
into  the  small  pelvis.  Perihepatitic  adhesions  of  the  liver  to  the 
abdominal  wall  and  to  adjacent  abdominal  viscera  may  also  pre- 
vent respiratory  displacement  of  the  liver.  At  the  beginning  of 
the  disease  it  is  highly  important  to  palpate  most  carefidly  the 
lower  border  of  the  liver  throughout  its  entire  extent,  as  it  is  just 
in  this  situation  that  carcinomatous  nodules  may  be  readily  and  dis- 
tinctly felt.  Naturally,  in  doul)tful  cases  the  surface  of  the  liver 
will  be  examined  repeatedly  for  projections.  It  is  often  possible 
in  the  course  of  the  disease  to  detect  newly  forming  nodules  and 
to  follow  the  growth  of  tliose  already  formed. 

In  the  differential  diar/nosix  it  is  important  in  the  first  place  to 
determine  that  a  tumor  in  the  region  of  the  liver  is  situated  in 


CARCINOMA    OF  THE  LIVER  347 

that  organ,  and  in  the  next  place  to  decide  as  to  its  carcinomatous 
nature.  In  connection  with  the  first  point  the  respiratory  dis- 
placement of  the  tumor  is  important,  as  this  occurs  in  addition 
only  in  connection  with  tumors  of  the  spleen,  and  generally  not  with 
tumors  of  the  stomach,  the  kidneys,  the  intestine,  or  the  mesentery. 
Besides,  it  should  be  noted  whether  the  tumor  is  situated  in 
the  area  of  hepatic  percussion-dulness,  and  whether  it  forms  a 
continuous  whole  with  this.  The  carcinomatous  nature  of  a  tumor 
of  the  liver  will  be  rendered  highly  probable  if  the  new-growth 
has  developed  spontaneously  after  the  fortieth  year  of  life,  and  has 
been  attended  with  rapid  emaciation.  As  compared  with  abscess 
of  the  liver,  it  should  be  noted  that  fluctuation  is  the  rule  when  the 
accumulation  of  pus  is  situated  superficially,  while  it  is  the  excep- 
tion with  carcinoma  of  the  liver.  Abscess  of  the  liver  is  usually 
attended  with  febrile  movement,  while  carcinoma  of  the  liver  is 
generally  unattended  with  elevation  of  temperature.  In  addition, 
the  etiology  must  be  taken  into  consideration  :  carcinoma  develops 
spontaneously,  while  abscess  is  preceded  by  traumatism,  gall-stones, 
ulceration  of  the  bowel  or  of  the  genitalia,  or  septicopyemia. 

Unilocular  echinococcus  of  the  liver  likewise  gives  rise  to  a  pro- 
jection from  the  surface  of  the  liver,  but,  in  contradistinction  from 
that  due  to  carcinoma,  the  former  is  attended  with  fluctuation, 
yields  hydatid  fremitus,  and  on  exploratory  puncture  gives  exit  to 
clear  watery  fluid  free  from  albumin,  in  which  microscopic  exam- 
ination discloses  at  times  the  presence  of  echinococcus-hooklets 
and  echinococcus-scolices. 

Great  difficulty  may  be  encountered  in  the  differentiation 
between  carcinoma  of  the  liver  and  multilocular  echinococcus  of 
the  liver,  as  both  diseases  are  attended  with  nodular  enlargement 
of  the  liver,  jaundice,  and  enlargement  of  the  spleen.  Multiloc- 
ular echinococcus  of  the  liver  is  an  exceedingly  rare  disease,  and, 
therefore,  in  doubtful  cases  carcinoma  of  the  liver  will  always  be 
the  more  probable  condition.  The  probability  will  be  all  the 
greater  should  the  patient  be  of  an  age  at  which  carcinoma  is 
common  and  have  become  cachectic  within  a  short  time.  In  the 
differential  diagnosis  of  carcinoma  of  the  liver  it  is  always  of  espe- 
cial importance  if  primary  carcinoma  be  found  in  any  other  viscus. 

Gummatous  nodules  in  the  liver  are  not  tender  on  palpation, 
and  there  must  have  been  a  history  of  previous  syphilis.  These 
tumors  diminish  and  disappear  upon  treatment  with  mercurials 
and  iodids. 

Should  the  liver  be  enlarged  but  present  a  smooth  surface,  the 
diagnosis  of  carcinoma  of  the  liver  will  always  be  involved  in 
doubt.  Naturally,  suspicion  should  invariably  be  aroused  if  jaun- 
dice develops  in  an  elderly  person  without  demonstrable  cause,  and 
if  in  the  course  of  about  four  weeks  this  does  not  diminish,  but 
rather  increases  in  intensity,  and  if  at  the  same  time  there  should 


348  DIGESTIVE  ORGANS 

be  rapid  loss  of  strength.  Jaundice  is  an  exceedingly  common, 
if  not  a  constant,  symptom  of  carcinoma  of  the  liver,  but  I  have 
noted  its  absence  in  a  number  of  instances  in  which  it  would  be 
most  readily  expected,  namely,  in  the  presence  of  carcinoma  of 
the  sail-bladder  Avith  extension  to  the  liver. 

The  development  of  jaundice  in  cases  of  carcinoma  of  the  liver  is  explained 
by  biliary  stasis  due  to  stenosis  of  the  biliary  passages  in  consequence  of 
pressure  exerted  by  the  carcinomatous  nodules.  At  times  jaundice  is  de- 
pendent upon  carcinomatous  degeneration  and  enlargement  of  the  portal 
lymphatic  glands,  with  pressure  upon  the  hepatic  duct. 

The  stools  are  frequently  deficient  in  bile  and  clay-colored, 
though  at  times  they  retain  their  natural  color,  because  the  bile 
that  enters  the  intestine  is  still  sufficient  to  discolor  the  fecal  mat- 
ter. It  may  also  happen  that  periods  in  which  the  stools  are  free 
from  bile  alternate  with  those  in  which  bile  is  present.  A  restor- 
ation of  the  lumen  of  the  biliary  passages  is  possible  from  the  re- 
duction in  size  of  the  neoplastic  nodules  in  consequence  of  fatty 
degeneration,  so  that  the  pressure  exerted  by  them  on  adjacent 
structures  varies.  Among  other  sequelae  of  jaundice  the  patients 
often  suffer  in  marked  degree  from  itching  of  the  skin — cutaneous 
pruritus — which  especially  disturbs  rest  at  night  and  contributes 
materiallv  to  exhaustion.  The  skin  is  often  the  seat  of  extensive 
exanthemata  and  of  bloody  and  encrusted  fissures  due  to  scratching. 
Enlargement  of  the  spleen  occurs  in  about  one-tenth  of  all  cases. 

Xot  rarely  abdominal  dropsy — ascites — develops,  and  this  may 
be  due  to  various  causes.  At  times  it  is  dependent  upon  the  general 
marasmus,  and  then  there  will  also  be  cachectic  edema  of  the  skin 
of  the  lower  extremities.  In  other  instances  the  ascites  is  due 
rather  to  local  causes  and  is  unattended  with  edema  of  the  extrem- 
ities. It  may  result  from  thrombosis  of  the  portal  vein,  and  from 
obstruction  of  the  portal  vein  due  to  pressure  exerted  by  enlarged 
carcinomatous  lymph-glands  in  the  transverse  fissure.  Carcinom- 
atous peritonitis,  as  a  rule,  gives  rise  to  the  same  symptoms  as 
ascites.  It  results  from  carcinomatous  inoculation  of  the  peri- 
toneum, and  causes  an  accumulation  of  either  serous  or  hemor- 
rhagic fluid,  usually  freely  movable  in  the  peritoneal  cavity. 
Occasionallv  excessive  tenderness  of  the  abdomen  on  manipulation 
is  indicative  of  the  presence  of  peritonitis.  Whether  the  condi- 
tion be  one  of  ascites  or  peritonitis,  in  either  instance  the  presence 
of  a  large  accumulation  of  fluid  in  the  abdominal  cavity  may  ren- 
der examination  of  the  liver  extremely  difficult  and  even  impossi- 
ble until  the  fluid  has  been  withdrawn  by  puncture. 

Individuals  suffering  from  carcinoma  of  the  liver  complain 
principallv  of  a  sense  of  tension  and  a  painful  feeling  in  the  right 
hypochondrium.  Severe  pain  in  the  liver  may  also  be  present,  such 
as  is  peculiar  to  almost  all  carcinomata,  and  is  prone  to  occur  par- 
ticularly at  night.     This  may  depend  upon  irritation  of  adjacent 


CARCINOMA    OF  THE  LIVER  349 

nerves. '  The  appetite  is  generally  wanting  entirely  ;  the  tongue  is 
usually  coated  ;  often  the  breath  is  fetid.  The  patients  frequently 
exhibit  eructation  and  vomiting  in  the  absence  of  primary  carci- 
noma of  the  stomach,  and  this  may  he  attributed  to  the  pressure 
exerted  by  the  enlarged  liver  upon  the  stomach.  In  addition,  in 
consequence  of  the  cachexia  the  gastric  juice  is  almost  entirely 
deprived  of  its  free  hydrochloric  acid,  while  the  absorption-period 
of  the  stomach  is  prolonged  and  its  motor  activity  is  diminished. 
Occasionally  the  supraclavicular  lymph-glands  upon  the  left  side 
are  enlarsred  and  indurated,  and  sometimes  also  the  inguinal 
glands.  This  condition  may  be  associated  with  primary  car- 
cinoma of  the  stomach,  although  I  have  observed  glandular 
enlargement  in  connection  with  primary  carcinoma  of  the  liver 
also.  As  a  rule,  carcinoma  of  the  liver  is  unattended  with 
alteration  in  temperature.  Nevertheless,  there  may  be  periods 
with  elevation  of  temperature,  and  this  may  even  assume  a  pro- 
nounced intermittent  type. 

Definite  statements  as  to  the  cJuration  of  carcinoma  of  the  liver 
can  hardly  be  made,  as  the  disease  begins  most  insidiously,  and  the 
time  of  its  inception  can  scarcely  be  determined.  In  general  a  year 
may  be  stated  to  be  the  maximum  duration,  although  death  may 
occur  much  earlier  from  a  rapidly  growing  neoplasm.  Even  when 
the  disease  sets  in  suddenly  with  jaundice  it  should  not  be  forgotten 
that  the  jaundice  has  probably  been  preceded  for  some  time  by  the 
development  of  carcinomatous  tumors.  Death  may  occur  under 
most  varied  conditions.  Often  it  is  the  result  of  jrrogressive  ex- 
haustion. Occasionally  evidences  of  blood-dissolution  appear — 
hemorrhages  into  the  skin  and  the  mucous  membranes,  particu- 
larly also  hemorrhage  from  the  stomach  (coffee-ground  vomiting), 
in  the  absence  of  carcinoma  of  the  stomach,  and  these  may  hasten 
the  exhaustion.  Occasionally  the  patients  die  rapidly  in  coma 
from  carcinomatous  intoxication,  which  may  be  dependent  upon 
auto-intoxication.  Excessive  accumulation  of  fluid  in  the  abdom- 
inal cavity  may  cause  death  by  suffocation,  but  at  the  present  day 
this  can  be  averted  by  abdominal  puncture — a  less  common  occur- 
rence is  rupture  of  a  carcinomatous  nodule  through  the  abdom- 
inal wall  or  into  the  abdominal  cavity,  or  into  an  adjacent  organ, 
wdth  its  ofteu  fatal  consequences.  Of  less  importance  is  extension 
of  carcinoma  of  the  liver  along  the  round  ligament  to  the  umbil- 
icus, with  the  development  of  carcinoma  and  carcinomatous  de- 
generation in  this  situation.  It  may  be  qttite  difficult  to  discover 
the  primary  focus  of  disease.  In  any  event  a  decision  as  to  pri- 
mary carcinoma  of  the  liver  should  not  be  reached  too  hastily,  but 
stomach,  rectum,  uterus,  esophagus,  and  mammary  gland  particu- 
larly should  be  carefully  examined  for  a  primary  focus.  Primary 
carcinoma  of  the  stomach  is  often  beyond  recognition  in  the  pres- 
ence of  carcinoma  of  the  liver,  because  the  enlarged  liver  conceals 


350  DIGESTIVE  ORGANS 

the  stomach  and  removes  it  from  immediate  examination,  and  the 
disturbances  of  gastric  activity  associated  Avith  carcinoma  of  the 
stomach  (deficiency  of  hydrochloric  acid  in  the  gastric  juice,  de- 
layed absorption,  enfeebled  motor  activity)  may  also  be  present  in 
the  absence  of  anatomic  alteration  in  the  stomach  solely  in  conse- 
quence of  the  cachexia  induced  by  carcinoma  of  the  liver.  I  have 
even  observed  coffee-ground  vomiting  in  several  cases  of  carcinoma 
of  the  liver,  while  at  the  autopsy  the  stomach  was  found  to  be  free 
from  malignant  disease. 

Prognosis. — The  prognosis  of  carcinoma  of  the  liver,  like 
that  of  carcinoma  elsewhere,  is  unfavorable.  Although  of  late 
attempts  have  been  made  to  remove  new-growths  of  the  liver  by 
surgical  means,  but  little  good  can  be  hoped  for  from  operation 
in  cases  of  carcinoma  of  the  liver,  because  the  lesion  is  almost 
always  a  secondary  one,  and  only  rarely  are  the  conditions  so 
favorable  as  to  permit  removal  also  of  the  primary  neoplasm  by 
operative  measures. 

Treatment. — Xo  specific  remedy  for  the  relief  of  carcinoma 
of  the  liver  is  known.  Symptomatic  treatment  will  include  regu- 
lation of  the  diet,  fats  in  particular  being  interdicted  in  the 
presence  of  jaundice.  In  other  respects  the  treatment  will  depend 
upon  particularly  prominent  symptoms  that  may  be  present. 

Among  the  remaining  tumors  of  the  liver,  only  sarcoma  and  adenoma 
are  of  clinical  interest.  Both  varieties  of  new-growth  give  rise  to  the  same 
symptoms  as  carcinoma  of  the  liver,  and  are  susceptible  of  differentiation 
only  at  autopsy,  and  at  times  only  after  microscopic  examination  of  the  tissue. 
Sarcoma  of  the  liver,  like  carcinoma,  is  usually  of  secondary  origin.  Melanotic 
sarcomata  occur  at  times  in  the  sequence  of  sarcoma  of  the  choroid,  even 
though  the  diseased  eye  have  been  removed  many  years  previously.  Occa- 
sionally they  give  rise  to  melanuria,  which  is  characterized  by  a  brownish 
or  blackish  color  of  the  urine  when  it  is  evacuated  or  after  standing  for  a 
time,  or  on  addition  of  oxidizing  substances  (chromic  acid,  dilute  sulphuric 
acid,  boiling  with  hydrochloric,  sulphuric,  or  nitric  acid). 

ECHINOCOCCUS  OF  THE  LIVER. 

!Etioiv)g"y. — Echinococcus-cysts  in  the  liver  represent  the 
measles  of  the  tapeworm  of  the  dog — Tcenia  echinococcus.  Echino- 
cocci  are  most  readily  acquired  by  those  who  come  into  frequent 
and  intimate  relation  with  dogs.  Echinococcus  is  most  prevalent 
in  Iceland,  where  every  seventh  inhabitant  is  said  to  be  the  victim 
of  the  disease.  Upon  the  Continent  of  Europe  Pomerania  and 
Mecklenburg  are  particularly  notorious  for  the  frequency  with 
which  echinococcus  occurs  among  their  inhabitants.  The  danger 
of  infection  is  particularly  great  when  the  vicious  practice  of  kiss- 
ing dogs  is  indulged  in,  or  these  animals  are  permitted  to  lick  the 
hands  or  the  face,  for  it  is  well  known  that  dogs  frequently  lick 
tiie  anus,  so  that  it  may  readily  hajipen  that  the  ova  of  the  Taenia 
echinococcus  remain  adherent  to  the  snout,  and  they  may,  in  the 


ECHINOCOCCUS  OF  THE  LIVER 


351 


act  of  licking  and  kissing,  become  deposited  upon  the  lips  or 
gain  entrance  into  the  mouth  of  human  beings.  If,  subsequently, 
with  the  ingestion  of  food  echinococcus-eggs  are  swallowed  by 
human  beings,  the  ova,  by  means  of  their  booklets,  and  probably 
by  way  of  the  gastric  veins  and  the  portal  vein,  pass  from  the 
stomach  into  the  liver,  where  they  develop  into  an  echinococcus-cyst. 
In  soiue  instances  they  penetrate  also  into  other  viscera,  although 
the  liver  is  the  organ  most  commonly  invaded  by  echinococci. 
Another  mode  of  infection  for  human  beings  consists  in  the  inges- 
tion of  echinococcus-ova  with  inadequately  cleansed  vegetables  that 
have  been  contaminated  by  the  feces  of  dogs  containing  such  ova. 
Contamination  of  water  also  with  the  feces  of  infective  dogs,  and 
infection  through  the  use  of  such  water,  may  likewise  take  place. 
The  especial  frequency  with  which  echinococcus-disease  occurs 
in  Iceland  is  due  to  the  large  number  of  dogs  that  are  kept, 
to  the  intimate  relation  between  the  inhabitants  and  domestic 
animals,  and  to  a  lack  of  domestic  cleanliness. 

Anatomic  Alterations. — Echinococcus  of  the  liver  occurs 
in  two  forms — as  a  unilocular  and  as  a  multilocular  echinococcus- 


FiG.  54.— Echinococcus-head,  with  retracted  rostellum  and  crown  of  booklets ;  magnified 
275  times  (personal  observation,  Zuricb  clinic). 

cyst.  The  latter  is  an  exceedingly  rare  condition  that  occurs 
with  comparative  frequency  in  Switzerland  and  in  AVurtemburg. 
Unilocular  echinococcus  of  the  liver  consists  of  a  vesicle  with  a 
whitish,  opaque,  milk-glass-like  wall,  whose  size  may  attain  that 
of  a  man's  head.  It  is  usually  possible  to  enucleate  the  cyst  from 
the  liver,  leaving  behind  a  connective-tissue  capsule  that  has  re- 
sulted in  consequence  of  interstitial  inflammation  of  the  liver  from 
the  irritation  exercised  by  the  echinococcus-cyst  upon  the  sur- 
rounding tissue.  Incision  of  the  echinococcus-cyst  generally  gives 
exit  to  a  clear  fluid.  This  resembles  water,  contains  no  albumin, 
but  frequently  succinic  acid,  and  consequently  on  addition  of  a 


352  DIGESTIVE  ORGANS 

dilute  solution  of  ferric  chlorid  assumes  a  brownish  color.  Not 
rarely  small  daughter-cysts  are  present  in  the  fluid,  and  even  in 
these  granddaughter-cysts  and  greMt-gr  and  daughter-cysts,  which 
may  exhibit  much  the  same  })ecu]iarities  as  the  mother-cyst.  It 
is  cliaractcristic  of  the  echinococcus-niembrane  that  its  cut  margins 
become  inverted.  It  may  be  readily  recognized  on  microscopic 
examination  from  the  fact  that  on  transverse  section  it  exhibits 
parallel  lines  or  layers,  which  have  been  appropriately  compared 
with  the  leaves  of  a  book.  Upon  the  inner  surface  of  echino- 
coccus-cysts  a  glandular  mass,  the  so-called  germinal  layer,  is 
found  as  a  rule.  Upon  this  are  situated  brood-capsules  with 
echiuococcus-heads  (scolices),  Avliich  may  be  readily  recognized 
from  the  presence  of  a  rostellum  and  a  crown  of  booklets  and 
four  suckers  (Fig.  54).  The  booklets  resist  destructive  influences 
for  a  long  time,  so  that  they  are  of  great  diagnostic  significance. 

At  times  echinococcus-cysts  occur  without  scolices — so-called  sterile  echi- 
nococcus-ci/sts  or  acephalocysts.  Echinococcus-cysts  may  undergo  suppura- 
tion. Often  their  contents  are  converted  into  a  viscid,  putty-like  mass,  in 
which  echinococcus-hooklets  are  demonstrable. 

Although  most  commonly  but  one  echinococcus-cyst  is  present 
in  the  liver,  exceptions  to  this  rule  have  been  observed.  Echino- 
cocci  are  most  frequently  seated  in  the  right  lobe  of  the  liver.  At 
times  other  viscera  also,  in  addition  to  the  liver,  are  the  seat  of 
echinococcus-cysts.  Multllocukir  echinococcus-cysts  convert  the 
liver  into  a  multinodular,  hard  organ,  which  upon  section  exhibits 
numerous  cysts  or  chambers  filled  with  softened,  pus-like,  gelat- 
inous masses.  Such  alterations  were  formerly  considered  as  due 
to  soft  carcinomata,  from  which,  however,  they  can  be  distin- 
guished with  certainty  by  the  discovery  in  them  of  echinococcus- 
hooklets  on  microscopic  examination.  The  condition  is  dependent 
upon  the  development  of  echinococci  within  previously  formed 
vessels,  most  commonly  the  biliary  passages  and  less  commonly 
the  portal  vein  or  the  lymphatics,  and  with  the  further  develop- 
ment continually  of  new  daughter-cysts  side  by  side. 

Symptoms  and  Diagnosis. — Patients  with  unilocular  echi- 
nococcHs  of  the  liver  complain  frequently  at  first  of  a  disagreeable' 
sense  of  tension  and  of  fulness  in  the  right  hypochondrium,  w  hic^h 
may  progress  to  marked  pain.  They  experience  a  sense  of  con- 
striction, and  suffer  from  dyspnea  and  palpitation  of  the  heart. 
On  examination,  the  liver  is  usually  found  enlarged,  and  its  limits 
may  be  extended  both  above  and  below.  It  is,  liowever,  of  ]iar- 
ticular  importance  to  demonstrate  the  presence  of  a  fluctuating 
prominence  upon  the  surface  of  the  enlarged  organ,  Mhich  corre- 
sponds with  the  echinococcus-cyst.  This  naturally  undergoes 
respiratory  displacement  with  the  liver.  It  is  highly  significant 
if  the  prominence  yields  hydatid  fremitus  on  percussion.  This 
consists  in  short-waved  vibration,  such  as  is  yielded  when  a  wire 


ECHINOCOCCUS  OF  THE  LIVER  353 

spring  is  tapped.  The  manifestation  is,  however,  by  no  means 
frequently  present.  It  is  most  distinetly  appreciable  if  the  per- 
cussion-hammer is  permitted  to  rest  upon  the  prominence  for  a 
few  seconds  following  each  blow,  or  if  the  middle  three  fingers  of 
the  left  hand  are  placed  upon  the  prominence,  and  the  central  one 
of  these  is  percussed  with  a  hammer  or  with  the  middle  finger  of 
the  right  hand.  In  rare  instances  the  hydatid  fremitus  is  asso- 
ciated wdtli  a  deep  sonorous  note  on  auscultation. 

In  the  differential  diagnosis  from  other  fluctuating  prominences 
upon  the  surface  of  the  liver,  soft  carcinomata  and  abscess  of  the 
liver  particularly  should  be  borne  in  mind.  Carcinoma  of  the 
liver,  however,  occurs  only  in  advanced  life,  is  attended  with 
rapid  emaciation,  and  is  usually  associated  with  the  presence  of 
primary  carcinoma  in  some  other  viscus  ;  while  abscess  of  the  liver 
is  attended  with  fever,  and  the  etiologic  factors  (gall-stones,  ulcer- 
ation in  the  intestine  and  the  genito-uriuary  apparatus,  septico- 
pyemia) should  be  taken  into  consideration.  Exploratory  punctm'e 
is  an  extreme  means  of  differentiation,  yielding  in  the  case  of 
echinococcus  of  the  liver  a  clear,  colorless,  watery  fluid,  contain- 
ing no  albumin,  but  booklets,  and  possibly  even  scolices  and  suc- 
cinic acid.  Whenever  possible,  exploratory  puncture  should  be 
avoided,  as  the  contents  of  the  cyst  may  readily  leak  into  the 
abdominal  cavity  through  the  orifice  of  puncture,  so  that  septic 
peritonitis  may  result,  or,  what  is  less  dangerous,  symptoms  of 
auto-intoxication  may  appear  in  the  form  of  widespread  urticaria. 
At  times  sudden  death  has  followed  exploratory  puncture,  and 
this  likewise  has  been  attributed  to  auto-intoxication. 

Naturally,  it  will  be  possible  to  feel  fluctuating  prominences  dis- 
tinctly upon  the  surface  of  the  liver  only  when  the  echinococcus-cyst 
is  applied  directly  to  the  abdominal  wall.  The  conditions  are  less 
simple  when  the  tumor  is  covered  by  the  thoracic  wall,  although  it 
may  be  that  the  cyst  is  applied  to  the  wall  with  such  j)ressure  as 
to  cause  enlargement  of  some  intercostal  spaces,  while  those  above 
and  below  are  crowded  together,  and  a  visible  projection  fornia 
externally,  which  may  yield  fluctuation  and  hydatid  fremitus. 
Occasionally  echinococcus-cysts  are  situated  in  the  neighborhood 
of  the  upper  border  of  the  liver,  and  are  thus  inaccessible  to  the 
eye  and  the  hand.  They  can  then  be  demonstrated  only  by  care- 
ful determination  of  the  upper  border  of  the  liver,  which  suddenly 
deviates  from  its  horizontal  course,  and  makes  a  marked,  usually 
hemispherical  deflection  upward  into  the  thoracic  cavity.  In  con- 
tradistinction from  encapsulated  pleural  exudates  and  subphrenic 
collections  of  pus,  this  projection  will  exhibit  respiratory  displace- 
ment. Here  also  exploratory  puncture  would  be  decisive  in 
doubtful  cases.  All  other  manifestations  attending  echinococcus 
of  the  liver  are  rather  of  accidental  and  therefore  of  subordinate 
importance.     Among  these  may  be  included  jaundice,  which  de- 

23 


354  DIGESTIVE  nncANS 

volops  when  pressure  is  exerted  upon  the  larger  hiliary  passages; 
uacitcs,  in  consequence  of  pressure  upon  the  trunk  of"  the  portal 
vein  ;  and  c/astro-intestinal  disturbances,  as  a  result  of  the  crowding 
of  the  abdominal  contents. 

The  ilanger  from  a  unilocular  echinococcus-cyst  of  the  liver 
depends  [)rineipally  upon  its  tendency  to  continued  r/roicth.  In 
consequence  the  diaphragm,  the  lungs,  and  the  heart  may  be  so 
greatly  displaced  upward  that  death  will  result  from  suffocation. 
Not  rarely  rupture  of  the  echinococcus-cyst  occurs  into  adjacent 
organs.  It  may  take  place  into  the  stomach,  as  will  be  indi- 
cated by  the  vomiting  of  echinococcus-vesicles.  Should  rupture 
occur  into  the  intestine,  the  urinary  passages,  or,  after  pre- 
vious adhesion  between  the  lungs  and  the  diaphragm,  into  the 
bronchial  tubes,  echinococcus-vesicles  will  appear  in  the  stools, 
the  urine,  or  the  expectoration  respectively.  The  expectoration 
under  such  conditions  acquires  a  penetrating,  aromatic  odor,  sug- 
gestive of  prune-juice.  At  times  it  is  also  characterized  by  a  red 
color,  in  consequence  of  the  abundant  presence  of  hematoidin- 
crystals.  Rupture  into  the  peritoneum,  the  pleura,  or  the  peri- 
cardium will  be  followed  by  peritonitis,  pleuritis,  or  pericarditis. 
Rarely  rupture  takes  place  into  the  hepatic  veins  or  the  inferior 
vena  cava.  Under  such  conditions  echinococcus-vesicles  may  gain 
entrance  into  the  right  heart  and  the  pulmonary  artery,  and  cause 
sudden  death  from  embolism  of  this  artery.  Rupture  through 
the  abdominal  walls  has  also  been  observed.  Should  suppura- 
tion take  place  in  an  echinococcus-cyst,  symptoms  will  appear  sim- 
ilar to  those  of  abscess  of  the  liver,  and  often  the  nature  of  this 
collection  of  pus  Avill  be  explained  only  by  the  discovery  in  it  of 
echinococcus-hooklets.  Echinococcus-cysts  situated  not  upon  the 
surface  of,  but  within,  the  liver  may  be  inaccessible  to  diagnosis 
during  life.  Under  favorable  conditions  a  probable  diagnosis 
might  be  made  in  tlie  presence  of  enlargement  of  the  liver  for 
which  no  other  cause  can  be  ascertained.  The  course  of  a  itni- 
locular  echinococcus-cyst  of  the  liver  is  usually  chronic,  and  may 
extend  over  several  years. 

MultUocular  ecltinococeus  of  the  liver  is  generally  attended  with 
profound  jaundice  and  enlargement  of  the  spleen.  The  liver  itself 
is  enlarged,  and  feels  unusually  hard  and  nodular.  The  disease 
mav  readily  be  confounded  especially  with  carcinoma  and  with 
hvpertrophic  cirrhosis  of  the  liver.  Carcinoma  of  the  liver,  how- 
ever, usually  develops  late  in  life,  and  in  association  with  primary 
carcinoma  in  some  other  viscus ;  and  hypertrophic  cirrhosis  of  the 
liver  with  jaundice  is  generally  attended  with  increase  in  the  size 
of  the  liver,  with  preservation  of  the  smoothness  of  its  surface. 
Death  occurs  generally  with  ]>rogressive  exhaustion,  but  at  times 
onlv  after  tlie  lapse  of  more  than  ten  years. 

Prognosis. — The  prognosis  of  echinococcus  of  the  liver  is 


DISPLACEMENTS  OF  THE  LIVER  355 

under  all  conditions  serious.  It  has  recently  been  rendered  less 
unfavorable  for  unilocular  cysts,  from  the  fact  that  cysts  have 
been  successfully  removed  by  operative  intervention. 

Treatment. — Prophylactic  measures  include  domestic  cleanli- 
ness, treatment  directed  to  the  expulsion  of  the  Taenia  echino- 
coccus  in  dogs,  and  the  avoidance  of  licking  by  dogs.  The 
kissing  of  dogs  may  be  followed  by  most  serious  dangers.  If 
echiuococcus-cysts  have  developed  in  the  liver,  they  should  be 
removed  by  operation.  Recently  atrophy  of  the  cysts  has  been 
induced  by  injections  of  mercuric  chlorid.  Internal  remedies  (po- 
tassium iodid,  ether)  and  affusions  of  a  solution  of  sodium  chlorid 
have  been  unattended  with  success.  In  the  presence  of  a  miilti- 
locular  echinococcus  of  the  liver,  there  is  scarcely  any  other  remedy 
than  the  relief  of  especially  threatening  or  troublesome  symptoms 
by  the  usual  measures.  Further,  a  large  portion  of  diseased  liver 
has  in  one  instance  been  successfully  removed  by  operative  means. 


DISPLACEMENTS  OF  THE  LIVER  (HEPATOPTOSIS), 

In  women  who  have  borne  children  the  liver  is  not  rarelv 
found  displaced  downward  and  unduly  mobile.  Obviously  relaxa- 
tion of  the  suspensory  ligaments  of  the  liver  and  of  the  abdominal 
walls  is  the  cause  of  this  condition.  Enlargement  of  the  liver,  as 
a  result  of  stasis,  of  fatty  or  amyloid  degeneration,  of  the  pres- 
ence of  parasites  or  of  neoplasms,  is  also  capable  of  causing  down- 
ward displacement  of  the  liver  in  consequence  of  the  increased 
weight  of  the  organ.  At  times,  however,  the  condition  appears 
to  be  dependent  upon  congenital  iceahness  of  the  suspensory  liga- 
ments of  the  liver,  or  such  weakness  may  be  acquired  as  a  result 
of  severe  or  protracted  disease.  Nervous  influences  also  are  of  sig- 
nificance. Bodily  over-exertion,  expulsive  efforts,  and  constric- 
tion by  clothing  favor  the  development  of  the  condition.  The 
degree  of  displacement  of  the  liver  is  susceptible  of  great  varia- 
tion. In  aggravated  cases  the  liver  may  be  found  in  the  pelvis, 
and  in  place  of  the  normal  hepatic  dulness  at  the  base  of  the  right 
chest  anteriorly  a  tympanitic  percussion-note  is  obtained  from  the 
presence  of  intestine,  and  this  will  disappear  when  the  liver  is 
replaced  in  its  normal  situation.  Such  a  condition  is  designated 
as  movable  or  ivandering  liver.  Further,  in  forming  an  opinion  as 
to  the  identity  of  a  foreign  body  in  the  abdominal  cavity  from  its 
shape  great  care  must  be  observed,  as  errors  have  been  made  in 
mistaking  a  movable  body  in  the  abdomen  for  a  wandering  liver, 
while  the  autopsy  has  disclosed  carcinoma  of  the  omentum.  It 
is  especially  important  if  one  or  two  incisures  (for  the  gall-bladder 
and  the  round  ligament)  are  found  in  the  lower  border  of  the 
liver.     At  times  the  stretched  round  ligament  also  may  be  pal- 


356  DIGESTIVE  ORGANS 

pable  tliroiigh  the  abdominal  wall.  Occasionally  wandering  liver 
is  detected  accidentally  upon  examination  of  the  abdomen.  If 
the  patient  on  palpating  the  abdomen  ha.s,  perhaps,  accidentally 
discovered  the  presence  of  a  movable  body,  he  is  often  so  greatly 
distressed  by  the  fear  that  the  condition  is  due  to  a  malignant 
neoplasm  that  a  positive  and  reassuring  opinion  on  the  part  of 
the  phvsician  will  be  required  to  convince  the  patient  that  the 
state  of  affairs  is  not  serious.  Some  patients  complain  of  a  dis- 
agreeable, at  times  also  painful,  sense  of  traction  and  tension  in 
the  abdomen,  and  gradually  become  nervous  and  hysterical. 
Derangement  of  intestinal  activity  also  may  develop  if  loops  of 
bowel  are  compressed  or  distorted. 

The  prognosis  is  favorable  with  regard  to  life  if  the  condi- 
tion is  not  dependent  upon  tumors  or  parasites,  although  it  is  often 
impossible  to  eifect  a  permanent  cure. 

The  treatment  must  generally  l)e  mechanical,  attempts  being 
made  by  means  of  abdominal  bandages  applied  to  the  lower  half 
of  the  abdomen  to  exert  pressure  upward,  and  thus  to  force  the 
liver  into  its  normal  situation.  Massage  of  the  abdomen  also  ap- 
pears worthy  of  recommendation.  Further,  attention  should  be 
given  to  the  general  condition. 

Congenital  displacement  of  the  liver  may  occur  in  association  with  trans- 
position of  the  viscera.  Under  such  conditions  the  liver  will  be  situated 
in  the  left,  and  the  spleen  in  the  right  concavity  of  the  diaphragm.  The  dis- 
placement may  involve  only  the  liver  and  the  spleen.  As  a  rule,  however, 
the  remaining  organs  of  the  thoracic  and  abdominal  cavities  are  correspond- 
ingly displaced.     The  condition  is  unattended  with  discomfort  or  danger. 


CONSTRICTED  OR  FISSURED  LIVER. 

Constricted  or  fissured  liver  may  result  from  tight  lacing.  The 
fissure  formed  is  generally  horizontal,  and  within  it  the  serosa 
covering  the  liver  is  thickened,  tendinous,  and  opaque.  Beneath 
the  fissure  the  liver-tissue  may  be  entirely  wanting,  so  that  a  por- 
tion of  the  liver  may  be  completely  constricted  off.  Often  the 
latter  is  thickened  and  exhibits  signs  of  blood-stasis.  Most 
commonly  the  lowermost  portion  of  the  right  lobe  of  the  liver 
is  constricted  off,  although  at  times  the  fissure  may  extend  with- 
out interruption  into  the  left  lobe.  Often  the  condition  remains 
latent  throughout  life  if  the  lower  border  of  the  liver  does  not 
extend  considerably  below  the  costal  margin.  Under  other  con- 
ditions a  horizontal  depression  may  be  palpable  upon  the  lower 
portion  of  the  surfiice  of  the  liver  beneath  the  al)dominal  wall. 
Below  this  depression  the  constricted  portion  of  liver  appears 
thickened,  and  at  times  can  be  reflected  upward.  Care  must  be 
taken  to  avoid  confusion  especially  with  a  syphilitic  lobulated 
liver.     The  condition  is  unattended  with  dano-er.     Internal  treat- 


CATARRH  OF  THE  BILIARY  PASSAGES  357 

ment  is  unnecessary,  and  would  also  yield  no  result.  Of  late  the 
constricted  portion  of  the  liver  has  been  removed  by  operation  in 
a  number  of  instances. 


DISEASES   OF   THE   BILIAKY   PASSAGES. 

CATARRH  OF  THE  BILIARY  PASSAGES  (CATAR- 
RHAL CHOLANGITIS  AND  CHOLECYSTITIS), 

Btiology. — Catarrli  of  the  biliary  passages  is  an  exceedingly 
common  disorder,  and  is  induced  particularly  by  infectious  or  toxic 
influences.  Most  commonly  it  is  secondary  to  catarrli  of  the  gas- 
troduodenal  mucous  membrane,  the  inflammatory  process  extending 
directly  from  the  mucous  membrane  of  the  duodenum  to  that  of 
the  choledoch  duet,  and  the  more  remote  biliary  passages.  At 
times  catarrh  of  the  biliary  passages  arises  in  the  sequence  of 
acute  or  chronic  infectious  diseases,  as,  for  instance,  fibrinous  pneu- 
monia, typhoid  fever,  erysipelas,  pharyngeal  diphtheria,  and  syph- 
ilis. Occasionally  catarrh  of  the  biliary  passages  occurs  as  an 
independent  infectious  disease.  Of  this  character  were  especially 
certain  epidemics  of  jaundice  that  have  at  times  been  observed  in 
over-crowded  dwellings  (barracks,  prisons),  in  the  secpience  of  re- 
vaccination  and  the  ingestion  of  spoiled  food  and  drink.  A  num- 
ber of  such  epidemics  have  occurred  particularly  in  the  autumn 
months.  At  times  children  were  attacked  in  especially  large 
numbers.  Among  the  toxic  catarrhal  staten  of  the  biliary  passages, 
that  following  phosphorus-poisoning  should  be  mentioned  particu- 
larly. This  may,  however,  leave  the  larger  biliary  passages  intact, 
and  attack  only  the  smaller  intrahepatic  biliary  passages.  The 
hypostatic  catarrh  of  the  biliary  passages  that  occurs  particularly 
in  association  with  chronic  disease  of  the  heart  and  the  respiratory 
organs  is  worthy  of  mention.  AYhether  circulatory  and  catarrhal 
alterations  in  the  biliary  passages  are  operative  in  connection  with 
the  jaundice  that  appears  in  some  women  shortly  before  and  during 
the  menstrual  period — so-called  menstrual  icterus — is  as  yet  unex- 
plained. Xot  rarely  gall-stones  cause  catarrh  of  the  biliary  pas- 
sages. Obviously  the  mechanical  irritation  of  the  mucous  mem- 
brane of  the  biliary  passages  h\  the  calculi  is  particularly  favora- 
ble to  the  deposition  of  micro5rganisms,  most  commonly  the  Bac- 
terium coli,  upon  the  mucous  membrane,  with  the  development  of 
an  inflammatory  process.  Not  rarely  diseases  of  the  liver  are  at- 
tended with  catarrh  of  the  biliary  passages,  often  because  by 
causing  obstruction  of  the  biliary  passages  they  give  rise  to  biliary 
stasis,  and  the  latter  may  be  followed  by  inflammation,  as  under 
such  circumstances  bacteria  readily  gain  entrance  into  the  biliary 
passages,  particularly  the  Bacterium  coli. 


358  DIGESTIVE  ORGANS 

Anatomic  Alterations. — In  tlie  presence  of  catarrli  in  the 
large  hiliarv  ducts  the  discliarge  of  bile  is  not  rarely  prevented  by 
a  p/«<7  of  vnicus.  At  times,  however,  the  phig  has  been  forced 
into  the  intestine,  so  that  its  previous  existence  can  only  be  recog- 
nized from  the  fact  that  the  biliary  passages  are  discolored  only 
up  to  the  point  previously  occupied  by  the  plug,  Avhile  they  are 
unstained  for  the  remaining  distance  to  the  intestine.  The  raucous 
membrane  is  often  conspicuous  by  reason  of  swelling  and  marked 
secretion  of  mucus.  Stenosis  of  the  biliary  passages  has  given  rise 
to  biliary  stasis,  and  thereby  to  the  icteric  manifestations  in  the 
liver  and  the  remaining  viscera  that  have  been  described  on  pp. 

321  and  322.  Catarrh  of  the  intrahepatic  biliary  passages  can  be 
demonstrated  in  the  smaller  biliary  channels  only  Avith  the  aid  of 
the  microscope,  active  desquamation  of  the  epithelial  cells  j^ar- 
ticularly  being  found. 

Symptoms,  Diagnosis,  and  Prognosis. — Catarrh  of  the 
biliary  passages  can  be  recognized  only  when  in  consequence  of 
the  formation  of  a  plug  of  mucus  and  tumefaction  of  the  mucous 
membrane,  biliary  stasis  and  hypostatic  and  resorptive  icterus  have 
developed,  and  which,  from  the  nature  of  the  causative  factors,  is 
also  designated  catarrhal  jaundice.  The  symptoms  are  identically 
those  that  have  been  described  on  pp.  317—321  in  the  general  con- 
sideration of  jaundice,  and  in  the  diagnosis  the  essential  point  is  to 
determine  Avhether  catarrh  of  the  biliary  passages  is  responsible 
for  the  jaundice.  In  this  connection  the  history  and  the  results 
of  physical  examination  of  the  viscera  are  of  great  importance. 
Often  previous  dietetic  error,  nausea,  vomiting,  constipation,  or 
diarrhea  will  leave  no  room  for  doubt  that  catarrh  of  the  biliary 
passages  has  been  preceded  by  gastroduodenal  catarrh,  and  the 
condition  is  then  designated  gastroduodenal  jaundice.  When 
primary  infectious  catarrh  of  the  biliary  passages  is  present  the 
pronounced  involvement  of  the  general  condition  is  often  striking. 
The  liver  and  particularly  the  spleen  are  consideraljly  enlarged. 
It  is  just  in  this  variety  of  catarrh  of  the  biliary  passages  that 
cholemia  may  readily  develop,  and  death  take  place.  The  dura- 
tion and  the  course  of  catarrhcd  jajindicc  depend  upon  the  caus- 
ative factors.  Recovery  from  gastroduodenal  jaundice  usually 
takes  place  within  one  or  two  weeks,  while  the  jaundice  accom- 
panying incurable  diseases  of  the  liver  persists  until  death.  Also 
the  prognosis  depends  naturally  upon  the  character  of  the  causative 
factors. 

Treatment. — In  the  first  place,  on  account  of  the  existing 
biliary  stasis  and  jaundice  the  diet  and  the  state  of  the  bowels 
should  be  regulated  in  accordance  with  the  rules  laid  down  on  pp. 

322  and  323.  Should  the  disorder  be  secondary  to  gastro-intestinal 
catarrh,  the  employment  of  acids  is  advisable.  Attempts  have  been 
made,  further,  to  cause  expulsion  from  the  biliary  passages  of  pes- 


PUR  ULEXT  INFLAMMATION  OF  THE  BILIARY  PASSAGES   359 

sible  accumulations  of  mucns  by  pressure  with  the  fingers  upon  the 
dilated  gall-bladder  not  rarely  distended  Ijy  accumulated  bile,  or 
by  inducing  contraction  by  means  of  the  faradic  current.  It  has 
been  stated  that  as  a  result  of  this  manipulation  a  gurgling  murmur 
is  appreciated,  after  which  the  biliary  passages  have  become  again 
patulous.  Particularly  troublesome  symptoms  of  jaundice  will 
require  the  treatment  described  on  pp.  322  and  323. 

PURULENT  INFLAMMATION  OF  THE  BILIARY 
PASSAGES  (PURULENT  CHOLANGITIS  AND 
CHOLECYSTITIS)* 

Purulent  inflammation  of  the  biliary  passages  scarcely  occurs 
apart  from  the  influence  of  bacteria,  and  according  to  previous  ex- 
perience particularly  of  the  Bacterium  coli  commune,  the  Strepto- 
coccus pyogenes,  the  Staphylococcus  pyogenes  albus  and  aureus,  the 
pneumoniacoccus,  and  the  typhoid-bacillus.  The  condition  is  usu- 
ally a  secondary  disorder,  occurring  particularly  in  connection  with 
the  presence  of  gall-stones  or  parasites  in  the  biliary  i^assages,  and 
with  infectious  diseases,  as,  for  instance,  in  the  sequence  of  typhoid 
fever,  and  occasionally  also  after  abscess  of  the  liver  and  pylephle- 
bitis. Anatomically  the  disorder  is  characterized  by  inflammation 
of  the  mucous  membrane  of  the  biliary  passages,  with  the  presence 
of  pus.  Occasionally  the  gall-bladder  particularly  is  filled  ^vith 
pus,  and  distended  thereby,  the  condition  being  designated  empyema 
of  the  gall-bladder.  The  disease  is  exceedingly  difficult  of  recog- 
nition. Particular  diagnostic  significance  should  be  attached  to 
the  etiologic  factors.  In  addition  there  will  be  the  clinical  picture 
of  general  septicopyemia  (fever,  enlargement  of  the  spleen,  meta- 
static inflammation  in  other  organs,  occasionally  ulcerative  endo- 
carditis). Of  importance  naturally  are  local  alterations  in  the  liver 
and  the  biliary  passages,  among  which  enlargement  of  the  liver, 
jaundice,  tenderness,  and,  in  the  presence  of  empyema  of  the  gall- 
bladder, the  demonstration  of  the  enlarged  gall-bladder,  with 
tenderness  on  pressure,  may  be  mentioned. 

The  prognosis  is  grave,  as  death  may  result  from  septico- 
pyemia, or  metastatic  su])puration,  or  rupture  of  the  biliarv  ducts 
into  the  liver,  with  the  formation  of  a  liver-abscess  ;  into  the  portal 
vein  or  the  hepatic  veins  ;  into  the  abdominal  cavity,  with  rapidly 
fatal  peritonitis  ;  or  into  some  other  internal  organ  ;  or  through  the 
abdominal  wall  in  the  presence  of  empyema  of  the  gall-bladder. 
In  tlie  last-named  event  a  biliary  fistula  may  develop,  from  which 
occasionally  numerous  gall-stones  are  evacuated  for  a  long  time. 

The  treatment  of  empyema  of  the  gall-bladder  is  surgical. 
The  gali-l)ladder  should  be  opened — cholecystotomy — and  pus  and 
gall-stones  evacuated  ;  or  it  should  perhaps  be  entirely  removed — 
cholecystectomy — tlie  latter  particularly  when  the  wall  of  the  gall- 


360  DIGESTIVE  ORGANS 

bladder  is  the  seat  of  profound  ulceration  and  alteration.  Should 
the  suppurative  inflammation  involve  rather  the  biliary  passages, 
it  may  also  become  necessary  to  expose  these,  to  incise  them, 
and  evacuate  the  calculi — choledochotomy ;  otherwise  the  only 
other  remedy  available  Mould  l)e  to  .sustain  the  strength  of  the 
patient  as  well  as  possible  by  means  of  the  administration  of  large 
amoimts  of  alcohol,  and  to  employ  disinfectants,  among  which 
sodium  salicylate  (1.0 — 15  grains — every  two  hours)  and  salol  (1.0 
— 15  grains — every  two  hours)  may  be  recommended.  In  addi- 
tion a  hot  cataplasm  should  be  applied  over  the  liver. 

DROPSY  OF  THE  GALL-BLADDER. 

The  conditions  for  the  development  of  dropsy  of  the  gall- 
bladder are  provided  whenever  permanent  occlusion  of  the  cystic 
duct  has  been  brought  about.  This  occurs  most  commonly  in  the 
presence  of  gall-stones,  either  because  a  gall-stone  has  become 
impacted  in  the  cystic  duct  or  because  in  its  progress  it  has  injured 
the,  wall  of  the  duct,  so  that  subsequently  adhesions  form  at  the 
site  of  injury.  Under  such  conditions  the  bile  is  gradually  ab- 
sorbed from  the  obstructed  gall-bladder,  while  a  colorless  mucoid 
fluid  takes  its  place.  The  amount  of  fluid  may  reach  40  quarts, 
so  that  the  gall-bladder  becomes  correspondingly  enlarged. 

Among  the  most  important  symptoms  of  dropsy  of  the  gall- 
bladder is  the  presence  of  enlargement  of  the  gall-bladder.  The 
gall-bladder  may  be  visible  to  the  eye  M'hen  the  abdominal  wall 
is  thin,  and  under  other  circumstances  it  may  be  palpable  as  a 
tensely  distended,  smooth,  pear-shaped  tiuuor.  From  a  diagnostic 
point  of  view  it  should  be  borne  in  mind  that  the  tumor  undergoes 
respiratory  displacement  Avith  the  liver,  is  situated  at  the  lower 
border  of  the  liver,  and  that  above  it  an  incisure  may  be  recog- 
nized, and  that  the  dulness  to  which  it  gives  rise  passes  over 
immediately  into  that  of  the  liver.  At  times  I  have  observed 
diagnostic  difficulties  to  arise  from  the  lodgment  of  the  trans- 
verse colon  between  the  lower  border  of  the  liver  and  the  lower 
extremity  of  the  gall-bladder,  so  that  the  tumor  to  which  the  latter 
gave  rise  was  separated  from  the  hepatic  dulness  by  a  tym]>anitic 
zone.  Further,  the  tumor  had  the  siiape  of  the  kidney,  and  was 
readily  movable  in  the  abdominal  cavity.  Slight  enlargement  of 
the  gall-bladder  scarcely  occasions  discomfort,  and  at  most  may 
cause  alarm  in  a  patient  who  accidentally  discovers  the  presence 
of  a  tumor  in  the  abdominal  cavity,  and  considers  it  carcinomatous. 
Excessive  dropsy  of  the  gall-bladder  causes  a  sense  of  tension  and 
pain  in  the  region  of  the  liver,  and  by  displacement  of  the  contents 
of  the  abdominal  cavity  may  give  rise  not  only  to  gastro-intestinal 
disturbances,  l)ut,  by  displacement  of  the  diaphragm  upward,  also 
to  dyspnea,  palpitation  of  the  heart,  and  danger  of  suffocation. 


PARASITES  IN  THE  BILIARY  PASSAGES  361 

Only  surgical  treatment  is  available.  Puncture  of  the  gall- 
bladder is  not  free  from  danger,  because  the  contents  of  the  viscus 
may  escape  into  the  abdominal  cavity  and  give  rise  to  fatal  peri- 
tonitis. Incision  of  the  gall-hladder — cholecystotomy — is  attended 
with  the  possibility  that  fluid  may  reaccumulate  in  the  gall-blad- 
der. Therefore  recovery  can  be  l)rought  about  most  certainly  by 
extirpation  of  the  gall-bladder — cholecystectomy. 

CARCINOMA  OF  THE  BILIARY  PASSAGES, 

Carcinoma  of  the  biliary  passages  is  situated  most  commonly  at 
the  mouth  of  the  choledoch  duct  or  in  the  gall-bladder  itself.  Car- 
cinoma at  the  mouth  of  the  choledoch  duct  gives  rise  to  chronic  jaun- 
dice, which  usually  terminates  fatally  with  progressive  exhaustion, 
and  the  cause  of  which  is,  as  a  rule,  not  recognized  during  life. 
Carcinoma  of  the  gall-bladder  gives  rise  to  the  development  of  a 
nodular,  usually  painful,  and  frequently  extensive  tumor,  situated 
in  the  region  of  the  gall-bladder,  usually  appearing  as  a  pear- 
shaped  swelling,  and  undergoing  respiratory  displacement  with  the 
liver.  The  percussion-dulness  of  the  liver  and  that  of  the  tumor 
are  continuous.  Frequently,  but  by  no  means  constantly,  jaundice 
is  present.  Often  the  neAv-growth  extends  to  the  liver,  and  a 
secondary  neoplasm  develops  in  this  organ,  ^vliich  may  attract  the 
greater  amount  of  attention.  Death  will  probably  occur  within  a 
year  amid  excessive  asthenia.  Like  carcinoma  in  other  organs, 
similar  disease  of  the  biliary  passages  usually  occurs  after  the 
fortieth  year  of  life.  The  causative  factors  remain,  as  a  rule,  un- 
recognized. The  frequent  association  with  gall-stones  suggests 
that  mechanical  irritation  may  excite  the  development  of  car- 
cinoma. Nevertheless,  the  gall-stones  may  also  have  developed 
secondarily  in  consequence  of  biliary  stasis.  The  significance  of 
the  gall-stones  appears  naturally  to  be  supported  by  the  fact  that 
in  cases  of  secondary  carcinoma  of  the  gall-bladder  calculi  do  not 
occur  in  this  viscus. 

The  prognosis  is  unfavorable,  as  with  carcinoma  in  other 
situations.  Recently  carcinoma  of  the  gall-bladder  has  been  suc- 
cessfully removed  with  the  knife  in  a  number  of  cases.  Beyond 
such  measures,  symptomatic  treatment  alone  will  be  applicable. 

PARASITES  IN  THE  BILIARY  PASSAGES. 

Parasites  in  the  biliary  passages  are  rare.  Echinoeocci  have 
already  been  mentioned  in  the  consideration  of  multilocular  echino- 
eocci of  the  liver.  Flukes — Distoma  hepaticum  and  Distoma  lanceo- 
latum — may  cause  jaundice,  purulent  inflammation  of  the  biliary 
passages,  and  suppuration  in  the  liver,  and  are  susceptible  of  recog- 
nition only  when  parasites  or  their  ova  are  present  in  the  stools. 


362  DIGESTIVE  ORGANS 

At  times  a  sjjool-worm — Ascaris  kimbricoides — may  wander  from 
the  intestine  into  the  biliary  passages  and  eanse  obstruction  and 
jaundice,  and  at  times  suppuration  in  tlie  liver  or  the  formation 
of  gall-stones. 

GALL-STONES  (CHOLELITHIASIS;, 

Ktiology. — Extremely  little  of  a  definite  nature  is  known 
as  to  the  causes  of  gall-stones.  Experience  has  shown  that  all 
those  conditions  favor  the  formation  of  gall-stones  that  cause 
biliary  stasis.  These  include  a  sedentary  mode  of  life  and  constrict- 
ing clothing.  Thus,  gall-stones  have  been  frequently  found  in 
association  with  constricted  liver.  Further,  they  occur  about  four 
times  as  frequently  in  women  as  in  men.  What  influence  food  may 
exert  is  unknown.  If  obesity  predisposes  to  the  formation  of  gall- 
stones, it  is  possible  that  biliary  stasis  is  principally  also  the 
actual  etiologic  factor,  as  a  result  of  the  crowding  in  the  abdom- 
inal cavity  in  consequence  of  the  excessive  fat  in  the  omentum 
and  the  mesentery.  Why  gall-stones  should  be  more  common  in 
certain  regions  than  in  others  is  as  yet  unexplained.  Children  but 
rarely  suffer  from  gall-stones,  which  generally  develop  after  the 
thirtieth  year  of  life. 

Anatomic  Alterations. — Gall-stones  develop  most  com- 
monly in  the  gall-bladder,  and  much  less  commonly  in  the  intra- 
hepatic biliary  passages.  Gall-stones  in  the  hepatic  duct,  the 
cystic  duct,  or  the  choledoch  duct  have  always  migrated  from  the 
gall-bladder  or  the  liver.  Gall-stones  consist  either  of  bilirubin 
and  lime-salts  or  of  cholesterin,  or  they  may  be  of  mixed  composi- 
tion, either  layers  of  bilirubin  and  lime-salts  and  cholesterin 
alternating  M^ith  each  other  on  cut  section,  or  the  one  constituting 
the  nucleus  or  the  outer  layer  of  the  calculus.  Bilirubin-calculi 
are  brownish  in  color,  while  cholestcrin-calculi  are  white,  upon 
section  present  a  crystalline  appearance  with  a  radiate  arrange- 
ment, and  yield  a  greasy  sensation  to  touch. 

Rarely,  biliary  calculi  consist  of  calcium  carbonate.  They  are  whitish  in 
color,  and  are  characterized  by  great  hardness. 

According  to  the  size  of  biliary  precipitates,  a  distinction  is  made 
between  biliary  sand  and  biliary  calculi.  The  former  possesses  the 
character  of  sand  and  may  attain  the  size  of  a  pin-head.  The 
size  of  gall-stones  depends  principally  upon  their  number,  for 
the  more  numerous  the  stones  the  smaller  must  they  be.  At  times 
the  entire  gall-bladder  is  occupied  by  a  single  gall-stone,  measur- 
ing several  centimeters  in  length  and  reproducing  the  pear-shape 
of  the  gall-bladder.  At  times  two  or  more  gall-stones  are  present 
in  the  gall-bladder,  and  these  may  be  in  contact  by  a  sort  of 
articular  surface.     The  number  of  gall-stones  may  reach   many 


GALL-STONES  363 

hundreds,  and  even  thousands.  Often,  gall-stones  that  lie  side  by 
side  in  considerable  number  acquire  peculiar  shapes.  They  have 
been  designated  facetted  gall-stones,  and  have  been  appropriately 
compared  with  the  shape  of  the  carpal  bones.  These  peculiarities 
are  not  dependent,  as  has  been  supposed  by  some,  upon  the  mutual 
attrition  of  adjacent  angles  and  surfaces,  but  upon  a  failure  in 
development  at  such  points  as  contiguous  stones,  which  originally 
possess  a  roundish  shape,  lie  in  contact.  Such  gall-stones  generally 
exhibit  extremely  smooth  surfaces,  as  if  polished.  In  contradis- 
tinction from  these  there  occur  also  globular  calculi,  with  a  multi- 
nodular surface,  and  these  have  been  designated  mulberry -calculi. 

Opinions  are  divided  as  to  the  mode  of  origin  of  gall-stones.  In  any 
event,  the  view  is  to  be  rejected  that  bilirubin  or  cholesterin  is  present  in 
the  bile  in  such  excessive  amount  as  not  to  be  retained  in  solution,  but 
to  be  precipitated.  As  experience  has  shown  that  biliary  stasis  favors  the 
formation  of  gall-stones,  there  is  much  in  favor  of  the  view  that  the  primary 
impulse  in  the  formation  of  gall-stones  is  to  be  referred  to  bacteria,  which, 
in  the  presence  of  biliary  stasis,  may  readily  gain  entrance  from  the  intes- 
tine into  the  biliary  passages.  In  the  first  place,  the  Bacterium  coli  com- 
mune will  suggest  itself,  because  it  is  a  constant  inhabitant  of  the  intestine. 
The  bacteria  excite  catarrhal  inflammation  of  the  mucous  membrane  of  the 
biliary  passages,  and  for  this  reason  some  clinicians  have  employed  the 
designation  calculus-forming  catarrh.  The  inflammatory  products  exert  a 
decomposing  influence  upon  the  biliary  acids,  and  as  the  biliary  salts  retain 
bilirubin  and  cholesterin  in  solution  in  the  bile,  these  substances  are  pre- 
cipitated when  decomposition  of  the  biliary  salts  takes  place.  The  precipi- 
tated constituents  of  the  gall-stones  do  not  simply  crystallize  together,  but 
are  held  together  by  an  organic  mass.  This  material  can  be  demonstrated 
when  gall-stones  are  carefully  dissolved.  In  some  instances  gall-stones  have 
been  found  to  develop  around  foreign  bodies  (prune-stones,  blood-clots, 
ascarides). 

Symptoms  and  Diagnosis. — Many  more  persons  suffer 
from  gall-stones  than  is  generally  believed,  because  often  the  cal- 
culi are  latent  and  occasion  no  symptoms.  At  times  gall-stones 
are  discovered  accidentally,  the  gall-bladder,  upon  examination 
for  some  other  cause,  being  found  to  be  not  only  enlarged,  but 
also  filled  with  gall-stones.  The  latter  will  be  recognized  as  hard, 
polyhedral  bodies,  which  not  rarely  can  be  rubbed  against  one 
another  with  a  palpable  crackling  sound,  and  yield  the  same  sen- 
sation as  when  a  bag  filled  with  small  pebbles  or  nuts  is  manipu- 
lated between  the  fingers.  In  cases  in  which  the  diagnosis  was 
doubtful  a  sterilized  needle  has  even  been  introduced  into  the 
gall-bladder,  and  observation  made  whether  a  hard  body  was  en- 
countered with  the  point  of  the  instrument. 

Rarely,  the  presence  of  gall-stones  is  disclosed  by  their  passage 
through  the  biliary  ducts  without  inducing  symptoms,  and  their 
discovery  accidentally  in  the  stools.  Gall-stones  often  give  rise  to 
hepatic  colic.  This  results  from  the  escape  of  the  calculi  from  the 
gall-bladder,  and  their  passage  through  the  biliary  ducts  into  the 


364  DIGESTIVE  ORGANS 

intestine.  Under  such  conditions  they  readily  become  impacted 
in  the  biliary  ducts,  causing  biliary  stasis  and  pain,  and  giving 
rise  to  the  clinical  picture  of  hepatic  colic.  Calculi  from  the 
intrahepatic  biliary  ducts  do  not  give  rise  to  hepatic  colic  in  their 
passage  into  the  intestine,  as  they  traverse  channels  that  in  com- 
parison with  their  site  of  origin  become  progressively  larger  as 
the  intestine  is  approached.  Frequently  no  especial  causes  for 
the  occurrence  of  biliary  colic  are  demonstrable,  while  in  some 
instances  anger  and  other  emotional  disturbances,  bodily  concus- 
sion, or  physical  over-exertion  has  been  an  antecedent  condition. 
jNIenstruation,  pregnancy,  and  the  puerperium  without  doubt  also 
favor  the  occurrence  of  attacks  of  hepatic  colic. 

The  principal  symptom  of  biliary  colic  is  pain.  This  is 
at  times  confined  strictly  to  the  region  of  the  gall-bladder  (exter- 
nal border  of  the  right  abdominal  rectus  muscle,  just  below 
the  right  costal  margin),  although  it  often  radiates  throughout  a 
larger  area,  particularly  toward  the  epigastrium,  the  right  scapular 
region,  and  often  also  to  the  right  arm.  The  pain  increases  par- 
ox  vsmally  to  an  unbearable  degree,  so  that  the  patients  cry  aloud 
and  groan,  exhibit  a  painful  and  anxious  expression,  and  are  cov- 
ered with  perspiration.  Occasionally,  there  may  be  loss  of  con- 
sciousness and  general  clonic  muscular  spasm,  obviously  because 
the  pain  causes  reflex  spasm  of  the  cerebral  arteries,  and  thereby 
cerebral  anemia.  A  chill  likewise  is  not  rarely  induced  by  reflex 
influences,  and  this  may  be  repeated  several  times.  Vomiting  also 
is  a  frequent  svnqjtom  dependent  upon  reflex  influences.  Often 
elevation  of  temperature  takes  place,  although  I  would  not  attrib- 
ute this  to  nervous  influences,  but  to  inflammation  of  the  biliary 
passages,  and  would  consider  it  an  indication  of  septic  general  in- 
fection. 

The  occurrence  of  jaundice  is  of  great  importance,  develop- 
ing on  the  average  in  the  course  of  three  days,  as  this  length  of 
time  is  necessarv  for  the  blood  to  become  sufticiently  saturated 
with  biliary  coloring-matter  in  order  to  stain  the  skin  and  the 
mucous  membranes  yellow.  The  degree  of  jaundice  varies  ex- 
tremelv ;  at  times  there  is  but  slight  yellowish  discoloration  of  the 
conjunctivae.  The  jaundice  naturally  persists  for  some  time  after 
the  attack  of  hepatic  colic,  until  the  biliary  coloring-matter  has 
been  removed  (principally  through  the  urine). 

It  is  noteworthy  that  when  the  choledoch  duct  is  obstructed  bv  a  gall- 
stone enlargement  of  the  gall-bladder  in  consequence  of  biliary  stasis  takes 
place  but  seldom. 

The  duration  of  an  attack  of  hepatic  colic  is  susceptible  of  great 
variation,  and  fluctuates  between  a  few  hours  and  as  many  weeks. 
In  the  latter  event  the  patients  are  never  free  from  pain,  although 
this  at  times  becomes  more  severe.     Under  such  conditions  they 


.    GALL-STONES  365 

not  rarely  lose  strength  in  an  alarming  degree.  There  are  also 
great  variations  in  the  recurrence  of  attacks  of  hepatic  colic.  One 
must  be  prepared  for  this  if  gall-stones  have  not  been  found  in  the 
stools,  in  spite  of  the  fact  that  these  have  been  thoroughly  dis- 
solved upon  a  sieve  in  a  stream  of  water.  To  obtain  assurance 
upon  this  point  the  stools  must  be  continuously  examined  for  at 
least  a  week  after  the  pain  has  disappeared,  as  biliary  calculi  may 
remain  for  some  time  in  the  intestine.  Gall-stones  naturally  will 
not  be  found  in  the  stools  if  they  slip  back  into  the  gall-bladder. 
The  occurrence  of  facetted  biliary  calculi  in  the  stools  will  justify 
the  anticipation  of  recurrent  attacks  of  hepatic  colic,  because  such 
calculi  are  usually  multiple  in  the  gall-bladder.  It  is^  further, 
noteworthy  that  biliary  calculi  in  the  stools  must  by  no  means 
always  have  passed  through  the  biliary  passages,  and  it  appears  to 
occur  not  at  all  rarely  that  they  give  rise  to  iuflammation  of  the 
biliary  passages  and  adhesions  to  the  bowel,  particularly  the 
transverse  colon,  and  then  after  perforation  gain  entrance  into  the 
bowel  through  a  biliary-intestinal  fistula.  When  gall-stones  have 
entered  the  bowel  the  clanger  is  not  always  passed,  for  occasionally 
they  may  occupy  the  lumen  of  the  intestine  in  such  a  peculiar 
manner,  or  a  number  of  stones  may  be  joined  together  by  fecal 
matter  into  so  large  a  mass,  as  to  cause  obstruction  of  the  bowel 
and  the  development  of  ileus. 

In  rare  cases  gall-stones  in  the  cecum  or  the  vermiform  appendix  give 
rise  to  typhlitis,  appendicitis,  perityphlitis,  or  paratyphlitis. 

Occasionally  biliary  calculi  become  so  firmly  impacted  in  the 
cystic  duct  or  the  choledoch  duct  that  they  cannot  be  moved  either 
forward  or  backward.  Such  impaction  of  gall-stones  is  attended 
with  the  danger  of  inflammation,  pressure-necrosis,  and  perforation 
of  the  gall-stones  into  the  abdominal  cavity,  and  this  will  gener- 
ally be  followed  by  rapidly  fatal  peritonitis.  Attacks  of  hepatic 
colic  are  not  always  attended  with  such  readily  recognized  mani- 
festations as  have  been  described.  Occasionally  they  give  rise 
to  vomiting  so  severe  and  persistent  as  to  arouse  suspicion  of 
ulceration  of  the  stomach.  At  times,  also,  the  pain  is  situated  in 
the  epigastric  region,  and  this  would  appear  to  strengthen  the 
suspicion  of  gastric  ulcer.  In  other  instances  pain  in  the  scapular 
region,  about  the  right  side  of  the  chest,  or  along  the  right  arm 
is  such  a  conspicuous  feature  that  gall-stones  may  be  confounded 
with  neuralgia.  At  times  chills  recur  daily  at  the  same  hour,  and 
the  clinical  picture  is  suggestive  of  intermittent  fever,  althougli 
malarial  plasmodia  are  not  found  in  the  blood.  If  the  pain  radi- 
ates actively  into  the  right  iliac  fossa,  care  will  be  necessary  to 
avoid  confusion  with  perityphlitis.  In  all  doubtful  cases  attention 
should  be  directed  to  the  occurrence  of  jaundice,  which  naturally 
often  occurs  in  slight  and  scarcely  appreciable  degree. 


366  DIGESTIVE  ORGANS 

111  addition  to  liepatic  colic  and  its  consequences,  biliary  calculi 
not  rarely  excite  inflammatory  alterafions  in  the  biliary  pa.s.s-ayr.s, 
suppuration  and  septicopyemia,  and  it  is  often  exceedingly  difficult 
to  recognize  them  under  such  conditions.  I  have  observed  ulcera- 
tive endocarditisi,  otitis  media,  and  inflammation  of  the  cerebral  sinuses 
develop  in  the  sequence  of  cholecystitis  due  to  gall-stones.  Occa- 
sionally abscess  of  the  liver  develops  as  a  result  of  gall-stones. 
Also  at  times  the  gall-bladder  becomes  attached  by  adhesions  to 
adjacent  organs  (stomach,  intestines,  urinary  passages),  ruptures 
into  these,  and  evacuates  its  calculous  contents  into  them,  so  that 
gall-stones  may  l)e  vomited  or  be  found  in  the  urinary  bladder. 
Occasionally  adhesions  to  the  abdominal  wall  form,  with  rupture 
of  the  gall-bladder  externally,  and  at  times  numerous  gall-stones 
are  evacuated  through  the  resulting  external  bilary  fistula  for  a 
considerable  length  of  time.  Rupture  of  gall-stones  into  the 
lungs  and  the  bronchi  has  also  been  observed.  Pericholecystitis  is 
a  common  sequel  of  gall-stones.  Gall-stones  may  j^ersist  at  times 
throughout  life.  Only  rarely  is  the  disease  terminated  with  a 
single  attack  of  hepatic  colic. 

Prognosis. — Hepatic  colic  is  a  serious  condition  under  all 
circumstances,  being  attended  M"ith  numerous  dangers,  whether 
the  calculi  exhibit  a  migratory  or  a  sessile  tendency.  It  should 
not  be  forgotten  in  this  connection,  however,  that  gall-stones  may 
excite  the  development  of  carcimoma  in  the  gall-bladder.  At 
times,  also,  connective-tissue  hyperplasia  develops  in  the  neigh- 
borhood of  the  biliary  passages  within  the  liver,  and  gives  rise  to 
biliary  cirrhosis  of  the  liver. 

Treatment. — Patients  with  gall-stones  generally  seek  profes- 
sional assistance  at  the  time  of  an  attack  of  hepatic  colic,  and  for 
the  relief  of  which  the  following  measures  may  be  adopted : 
Patients  should  remain  in  bed  and  apply  a  hot  poultice  over  the 
region  of  the  liver.  They  should  partake  of  liquids  only,  such  as 
weak  tea,  milk,  and  wine,  diluted  with  water.  If  the  pain  is 
severe,  a  suhcutaneous  injection  of  morphin  should  be  given  : 

R   Morphin  hydrochlorate,  0.3  (4-2  grains), 

Glycerin, 

Distilled  water,  each,  5.0  (75  minims). — M. 

Dose:  From  0.25  (4  minims)  to  0.5  (8  minims)  subcutaneously. 

The  patient  should  never  be  entrusted  with  morphin  and  a 
syringe  for  use  upon  himself  because  the  danger  and  the  tempta- 
tion are  too  gr^at  to  make  injections  when  not  necessary,  and 
gradually  to  employ  larger  doses  of  the  drug,  and  finally  to  become 
a  morphin-habitue.  Daily  rectal  injections  of  water  at  room-tem- 
perature may  l)e  recommended,  as  stimulation  of  intestinal  peri- 
stalsis a})pears  to  favor  the  passage  of  the  gall-stones  through  the 
biliary  channels. 


GALL-STONES  ■  367 

Enemata  of  oil  have  been  advised  by  some  physicians.  Olive-oil  (180.0 — 
6  fluidounces)  internally  and  glycerin  have  been  recommended  to  facilitate 
the  passage  of  gall-stones  and  for  the  relief  of  attacks  of  hepatic  colic. 

"When  an  attack  of  biliary  colic  has  been  successfully  relieved, 
efforts  should  next  be  made  to  effect  solution  of  gall-stones  still 
present,  and  to  prevent  the  formation  of  new  calculi.  Oil  of  tur- 
pentine and  ether  in  the  form  of  Durande's  remedy  especially  have 
been  recommended  as  a  solvent : 

B   Oil  of  turpentine,  5.0  (75  minims), 

Ether,  _  _  20.0  (  5  iuidrams).— M. 

Dose :  20  drops  four  times  daily, 

A  solvent  action  by  this  mixture  can  naturally  be  expected 
only  upon  cholesterin-calculi.  JSTevertheless  an  undeniable  effect 
upon  bilirubin-calculi  also  is  at  times  observed,  but  under  such 
conditions  the  result  must  be  attributed  less  to  a  solvent  action 
than  to  the  circumstance  that  the  remedy  stimulates  the  secretion 
of  bile.     Sodium  salicylate  acts  in  the  same  way  : 

R  Sodium  salicylate,  1.0  (15  grains). 

Make  10  such  powders. 

Dose  :  1  powder  thrice  daily  after  eating. 

The  administration  of  bile  and  its  sodium-combination  also  favors 
the  secretion  of  bile,  and  may  be  advised  in  the  treatment  of  gall- 
stones. Courses  of  treatment  with  the  waters  at  springs  are  much 
employed,  particularly  at  Carlsbad,  Marienbad,  Tarasp,  Kissingen, 
Homburg,  Ems,  Wiesbaden,  and  Vichy.  That  these  waters  are 
capable  of  exerting  a  solvent  effect  has  not  been  demonstrated ; 
they  do,  however,  influence  favorably  the  catarrhal  conditions 
of  the  gastro-intestinal  mucous  membrane  and  the  biliary  pass- 
ages, and  in  this  way  may  prevent  the  formation  of  gall-stones. 
Persons  in  moderate  circumstances  may,  with  the  same  object  in 
view,  use  artificial  Carlsbad  salt  for  periods  of  four  weeks : 

R  Artificial  Carlsbad  salt,  100.0  (3  ounces). 

Dose :  1  teaspoonful  in  a  pint  of  tepid  water,  to  be  taken  in 
four  equal  parts  at  intervals  of  ten  minutes. 

Persons  suffering  from  gall-stones  should  take  considerable  exer- 
cise, not  wear  constricting  clothing,  secure  a  daily  evacuation  of 
the  bowels,  and  avoid  all  conditions  capable  of  causing  biliary 
stasis. 

Recently  the  operative  treatment  of  gall-stones  has  occupied 
attention.  Surgical  intervention  will  be  justified  in  the  presence 
of  impaction  of  a  gall-stone  in  a  biliary  duct.  With  this  end  in 
view  the  abdomen  should  be  opened,  the  stone  located  in  the  biliary 
duct,  and  an  attempt  made  by  gentle  pressure  to  force  its  entrance 


368  DIGESTIVE  ORGANS 

into  tlie  intestine  or  the  gall-bladder,  or  to  crush  it  between  the 
fingers — cholelithotripsy.  Otlierwise,  it  would  be  necessary  to  incise 
the  bile-duct — choledochotomy — extract  the  stone,  and  suture  the 
margins  of  the  wound.  At  times  inn^acted  calculi  remain  in 
situ  without  exciting  inflammation,  although  the  chronic  hypo- 
static jaundice  gives  rise  to  alarming  emaciation.  Under  such  cir- 
cumstances choleci/denterostomy  has  been  performed ;  that  is,  an 
artificial  communication  has  been  established  between  the  gall- 
bladder and  the  highest  possible  loop  of  small  intestine.  It  may 
happen,  of  course,  that  the  biliary  passages  are  infected  with  bac- 
teria from  the  intestine,  and  become  inflamed.  Should  there  be  a 
marked  tendency  to  the  formation  of  gall-stones,  and  should 
attacks  of  hepatic  colic  occur  with  such  frequency  as  to  make  the 
life  of  the  patient  miserable,  or  should  empyema  of  the  gall- 
bladder have  developed  in  consequence  of  the  presence  of  gall- 
stones, this  viscus  has  been  incised — cholecy  slot  amy — or  it  has  been 
removed — cholecystectomy.  The  latter  operation  is  scarcely  more 
dangerous  than  the  first,  and  has  the  further  advantage  that  no 
new  gall-stones  can  form  in  the  gall-bladder.  Under  the  Avorst  of 
circumstances  the  development  of  gall-stones  in  dilatations  of  the 
large  biliary  ducts  would  be  possible.  AYhen  gall-stones  have 
become  impacted  in  the  intestine,  and  symptoms  of  ileus  have 
developed,  abdominal  section  has  been  performed,  the  bowel  in- 
cised, the  calculus  extracted,  the  intestine  and  the  abdomen  sutured, 
and  cure  effected  in  this  wav. 


DISEASES   OF  THE  BLOOD-VESSELS   OF 
THE   LIVER. 

THROMBOSIS  OF  THE  PORTAL  VEIN 
CPYLETHROMBOSIS;, 

Ktiology. — As  in  other  blood-vessels,  thrombi  may  form  in 
the  portal  vein  as  a  result  of  compression,  of  slowing  of  the  blood- 
stream, and  of  marantic  conditions.  Fressure-thrombosis  is  observed 
in  connection  with  tumors  surrounding  the  trunk  of  the  portal 
vein,  as,  for  instance,  carcinoma  of  the  pancreas,  stomach,  or  intes- 
tine, enlargement  of  the  portal  lymphatic  glands,  and  at  times  also 
as  a  result  of  compression  due  to  peritonitic  adhesions.  Tlirombosis 
of  the  portal  vein  due  to  slowing  of  the  hlood-sfrraiii  develops  par- 
ticularly in  association  with  certain  diseases  of  the  liver,  most 
commonly  chronic  interstitial  hepatitis  and  carcinoma  of  the  liver. 
Marantic  pylethrombosis  is  observed  finally  in  the  sequence  of  pro- 
tracted and  del)ilitating  diseases,  among  which  chronic  diarrhea, 
carcinoma,  and  pulmonary  tuberculosis  may  be  mentioned.  Throm- 
bosis of  the  portal  vein  is  a  rather  uncommon  disorder. 


THROMBOSIS  OF  THE  PORTAL    VEIN  369 

Symptoms,  Diagnosis,  Prognosis,  and  Anatomic 
Alterations.. — Obstruction  of  the  trunk  of  the  portal  vein  by  a 
thrombus  gives  rise  necessarily  to  increase  in  the  blood-pressure 
in  the  portal  area,  and  consequently  to  portal  stasis.  The  latter  is 
manifested  by  the  occurrence  of  ascites,  splenic  enlargement,  hypo- 
static catarrh  of  the  stomach  and  the  intestine,  and  hemorrhoids,  at 
times  of  hemori-hage  from  the  mucous  membrane  of  the  stomach  and 
the  intestine.  Jaundice  also  may  develop,  and  this  has  been  ex- 
plained by  the  fact  that  in  consequence  of  the  thrombosis  the 
blood-pressure  in  the  intrahepatic  branches  of  the  portal  vein  has 
fallen  so  low  that,  contrary  to  the  rule,  bile  can  pass  over  from  the 
biliary  capillaries  into  the  portal  branches.  It  is  therefore  evident 
that  the  same  conditions  are  present  as  in  cirrhosis  of  the  liver,  and 
nothino;  else  would  be  expected,  as  in  the  latter  disorder,  also,  the 
portal  area  is  partially  obstructed  and  partially  constricted,  although 
the  process  involves  not  the  trunk  of  the  portal  vein,  but  its  intra- 
hepatic branches.  It  has  even  been  maintained  that  pylethrom- 
bosis  gives  rise  to  chronic  interstitial  hepatitis,  but  this  view  has 
not  unjustly  been  contradicted. 

The  diferential  diagnosis  between  cirrhosis  of  the  liver  and  pyle- 
thrombosis  can  scarcely  ever  be  made  with  certainty.  Excessive 
indulgence  in  alcohol  is  suggestive  of  cirrhosis,  which,  further,  is 
rather  a  common  disorder.  Pylethrombosis  may  also  be  readily 
confounded  with  chronic-serous,  tuberculous,  and  carcinomatous  peri- 
tonitis, and  in  the  diflPerentiation  the  points  mentioned  on  page  336 
should  be  borne  in  mind. 

The  prognosis  of  pylethrombosis  is  not  favorable,  for  even  if, 
as  in  cirrhosis  of  the  liver,  venous  collateral  channels  develop,  for 
the  purpose  of  conveying  the  portal  blood  to  the  general  circula- 
tion, these  will  not  suffice.  The  ascites  increases  progressively, 
and  death  appears  unavoidable  from  asphyxia,  cardiac  paralysis, 
exhaustion,  at  times  from  excessive  hemorrhage. 

The  anatomic  alterations  are  readily  recognizable.  On  divid- 
ing the  trunk  of  the  portal  vein  this  vessel  will  be  found  occluded 
by  a  fibrinous  thrombus  which  at  times  may  be  followed  far  into 
the  intrahepatic  or  the  peripheral  branches.  Mural  thrombi  that 
have  occasioned  only  stenosis  of  the  portal  vein  are  less  com- 
mon.    In  addition  the  changes  due  to  portal  stasis  are  present. 

Treatment. — The  treatment  of  portal  thrombosis  is  mechan- 
ical. Abdominal  puncture  should  be  performed  when  the  ascites 
becomes  excessive.  From  internal  remedies,  such  as  digitalis, 
calomel,  diuretin,  urea,  and  other  diuretics,  and  from  laxatives, 
diaphoretics,  or  drastics,  no  permanent  success  can  be  hoped. 
Also  absorption  of  the  thrombus  by  medicaments  cannot  be 
effected. 

24 


370  DIGESTIVE  ORGANS 

PURULENT  INFLAMMATION  OF  THE  PORTAL  VEIN 
(SUPPURATIVE  PYLEPHLEBITIS). 

^Etiology. — Siij)])urative  pylephlebitis  is  a  nuiiiifestation  of 
septicopyemia.  It  develops  in  the  sequence  of  inflammation  in 
the  radicular  distribution  of  the  portal  vein  if  bacteria  gain  en- 
trance into  the  portal  vein  from  this  point,  excite  inflammation 
of  the  wall  of  the  vein,  and  in  connection  therewith  give  rise  to 
the  formation  of  a  purulent  thrombus  contaminated  by  bacteria. 
Among  the  more  common  causes  are  dysentery,  puerperal  fever, 
carcinoma  of  the  uterus,  salpingitis,  oophoritis,  carcinoma  of  the 
rectum,  proctitis  and  periproctitis,  peritonitis,  perityphlitis,  abscess 
of  the  spleen,  gastric  ulcer,  carcinoma  of  the  stomach,  and  intes- 
tinal ulceration.  In  the  newborn  pylephlel)itis  has  been  observed 
in  the  sequence  of  inflammation  of  the  uml)ilicus. 

Anatomic  Alterations. — The  wall  of  the  portal  vein  appears 
friable  and  readily  torn  in  the  diseased  situation.  On  opening  the 
vein  a  smeary,  purulent,  at  times  offensive-smelling,  brownish 
thrombotic  mass  is  found  at  this  point.  Often  portions  of  the 
throml)us  have  become  detached,  and  have  found  their  wav  into 
the  liver,  where  they  give  rise  to  new  foci  of  inflammation  and 
suppuration.  Collections  of  pus  form  also  in  other  viscera,  par- 
ticularly in  the  lungs.  The  spleen,  as  in  many  infectious  diseases, 
is  enlarged  and  soft. 

Symptoms,  Diagnosis,  and  Prognosis. — The  disease 
pursues  the  course  of  a  septicopyemia.  Repeated  chills  occur, 
and  are  followed  by  fever  and  sweating.  The  liver  and  the 
spleen  are  enlarged.  Pressure  over  the  liver  induces  pain.  At 
times  it  has  been  possible  to  feel  the  portal  vein  through  the 
abdominal  walls  as  a  thick  cord.  Often  there  is  marked  jaundice. 
Kot  rarely  foci  of  purulent  inflammation  appear  in  various  parts 
of  the  body,  as,  for  instance,  the  lungs,  the  pleura,  the  pericar- 
dium, and  the  joints.  Lender  the  most  favorable  conditions  the 
diagnosis  can  be  made  only  with  some  degree  of  probability. 
The  prognosis  is  unfiivorable,  as  recovery  appears  impossible. 

Treatment. — Efforts  should  be  made  to  maintain  the  forces 
of  the  body  as  fully  as  possible,  particularly  by  the  use  of  alco- 
holics and  stimulants.  In  addition,  an  ice-bag  should  be  applied 
over  the  liver. 

ANEURYSM  OF  THE  HEPATIC  ARTERY. 

But  a  small  number  of  cases  of  aneurysm  of  the  hepatic  artery 
have  been  recorded.  The  condition  can  be  recognized  with  cer- 
tainty only  when  a  swelling  Avith  exjiansile  pulsation  is  palpable 
to  the  right  of  the  median  line,  and  over  which  a  cardiac-systolic 
vascular  murmur  is  audible.     At  times  symptoms  are  present  like 


DISEASES  OF  THE  PANCREAS  371 

those  of  biliary  colic  :  Colicky  attacks  of  pain,  vomiting,  and  jaun- 
dice. In  one  case  under  my  observation  deatli  resulted  from  inter- 
nal hemorrhage,  the  cause  of  which  was  found  on  post-mortem 
examination  to  be  a  ruptured  aneurysm  of  the  hepatic  artery. 

The  prognosis  is  unfavorable,  for  every  aneurysm  has  a 
tendency  to  undergo  enlargement  and  rupture. 

The  treatment  would  be  confined  to  the  relief  of  particularly 
distressing  symptoms.  If  the  diagnosis  is  positive,  persistent  rest 
in  bed  and  the  application  of  an  ice-bag  would  be  indicated. 


VII.   DISEASES  OF    THE   PANCREAS. 


The  diagnosis  of  disease  of  the  pancreas  is  exceedingly  difficult, 
for,  in  the  first  place,  the  organ  is  so  concealed  as  to  be  accessible 
to  physical  examination  only  under  especially  favorable  condi- 
tions, and,  besides,  no  symptoms  are  known  to  be  peculiarly  dis- 
tinctive of  disease  of  the  pancreas. 

Acute  and  chronic  inflammation  of  the  pancreas  is  thus  far  only 
of  anatomic  interest. 

[Acute  pancreatitis  may  be  hemorrhagic,  suppurative,  or  gangrenous. 
It  is  attended  with  pain  in  the  superior  abdominal  region,  usually  of  sudden 
onset  and  paroxysmal  exacerbation  ;  generally  with  constipation,  although 
diarrhea  may  supervene ;  with  abdominal  distention,  icterus,  an  anxious 
and  pinched  expression,  a  small  and  rapid  pulse,  and  variable  temperature. 
Death  usually  occurs  in  from  two  to  five  days,  from  collapse.  In  treatment 
morphin  may  be  required  for  the  relief  of  pain,  and  stimulants,  possibly  by 
enema,  to  overcome  collapse.  If  the  pancreas  can  be  felt  to  be  enlarged 
and  the  diagnosis  is  certain,  operation  and  evacuation  of  septic  material 
may  be  undertaken  as  soon  as  collapse  has  passed  off. 

Chronic  pancreatitis  probably  arises  by  extension  from  adjacent  disease. 
It  may  set  in  gradually  and  without  pain,  or  with  severe  epigastric  pain, 
associated  with  nausea  and  vomiting,  or  followed  by  jaundice  and  perhaps 
also  by  a  feeling  of  chilliness  or  a  rigor.  Tenderness  is  usually  present  in 
the  umbilical  region,  and  sometimes  swelling  of  the  pancreas  can  be  made 
out.  Appetite  is  usually  wanting ;  the  taking  of  food  is  followed  by  epigas- 
tric discomfort,  and  loss  of  flesh  and  strength  is  marked.  Albuminuria  is 
common,, and  glycosuria  may  be  present.  The  temperature  is  variable.  At 
a  late  stage  hemorrhages  may  take  place  into  the  skin  and  from  the  mucous 
membranes,  with  death  from  asthenia.  In  diagnosis  gall-stones  in  the 
choledoch  duct,  carcinoma  of  the  head  of  the  pancreas  or  of  the  liver  and 
the  bile-ducts,  and  chronic  catarrh  of  the  bile-ducts  must  be  taken  into 
consideration.     The  only  treatment  is  surgical. — A.  A.  E.] 

In  obese  persons  fat-necrosis  occurs  occasionally  in  the  pancreas, 
and  in  connection  therewith  there  may  be  hemorrhage  into  the  pan- 
creas. Under  such  circumstances  deatli  takes  place  amid  signs  of 
shoek  and  progressive  collapse,  or  the  pancreas  undergoes  marked 
increase  in  size,  exerts  pressure  upon  the  intestine,  and  gives  rise 


372  DIGESTIVE  ORGANS 

to  ileuH,  or  rupture  into  the  abdominal  cavity  takes  place,  with 
the  development  of  usually  fatal  peritonitis. 

At  times  calculi  fonn  in  the  excretory  ducts  of  the  pancreas — 
pancreatic  sialolithiasis — and  these  may  give  rise  to  severe  and 
painful  attacks  of  pancreatic  colic. 

Pancreatic  cysts  have  been  operated  upon  recently  in  a  number 
of  instances. 

Carcinoma  of  the  pancreas  may  involve  the  tail,  the  body,  the 
head,  or  the  entire  organ.  jNIost  commonly  the  head  is  the  seat 
of  the  disease.  Generally  the  new-growth  is  primary.  The  most 
reliable  sign  is  the  demonstration  of  a  nodular  tumor,  somewhat 
above  the  level  of  the  umbilicus,  not  connected  with  the  stomach, 
the  omentum,  the  colon,  tiie  kidneys,  the  liver,  or  the  abdominal 
lymphatic  glands.  Carcinoma  at  the  head  of  the  pancreas  often 
surrounds  the  portal  vein  and  the  choldeoch  duct,  and  occasions 
irremediable  ascites  and  jaundice.  The  prognosis  is  unfavorable 
and  the  treatment  purely  symptomatic. 


VIII.    DISEASES   OF  THE   PERITONEUM. 


INFLAMMATION  OF  THE  PERITONEUM 
(PERITONITIS). 

etiology. —  Inflammation  of  the  peritoneum  in  human  beings 
occurs  almost  unexceptionally  as  a  result  of  the  activity  of  bacteria, 
among  which  the  Bacterium  coli  commune,  the  Streptococcus 
pyogenes,  the  Staphylococcus  pyogenes  albus  and  aureus,  the 
pneumoniacoccus,  the  gonococcus,  the  Bacillus  typhosus,  the  Ba- 
cillus tuberculosis,  and  some  others  have  been  demonstrated  in  the 
inflammatory  lesions.  Naturally  it  would  be  possible  to  excite 
peritonitis  by  means  of  strictly  chemic  poisons,  as  for  instance, 
injections  of  oil  of  turpentine,  tincture  of  iodin,  and  the  like,  into 
the  abdominal  cavity,  but  such  an  occurrence  is  only  exceptionally 
to  be  anticipated  in  human  beings. 

Infection  of  the  peritoneum  is  usually  brought  about  through 
certain  contributory  causes,  which  formerly,  when  the  significance 
of  bacteria  was  not  understood,  were  considered  the  active  and 
causative  factors  of  the  disease.  Among  these  the  greatest  im- 
portance was  attached  to  cold.  Rcfrif/cratory  (rheumatic)  peri- 
tonitis  is,  however,  among  the  less  common  varieties  of  the  dis- 
ease. It  has  been  observed  after  sleeping  upon  damp  ground, 
and  particularly  in  WM)men,  at  the  menstrual  period,  following 
cold  bathing.  At  times  traumatism  is  followed  by  infection  of 
the    peritoneum   and  the   development   of  traumatic  peritonitis. 


INFLAMMATION  OF  THE  PERITONEUM  373 

Falls,  blows,  shocks,  crushing,  and  punctured  wounds  of  the 
abdomen,  may  be  mentioned  as  particularly  common  causes  of 
traumatic  peritonitis. 

Peritonitis  by  extension  probably  occurs  most  commonly,  and 
particularly  in  the  sequence  of  inflammatory  and  ulcerative  pro- 
cesses in  any  of  the  intestinal  viscera,  and  in  the  vicinity  of  the 
peritoneum.  It  will  suffice  to  mention  a  number  of  the  more 
common  disorders :  ulcer,  abscess,  and  carcinoma  of  the  stomach, 
ulceration  of  the  intestine,  dysentery,  carcinoma  of  the  intestine, 
intestinal  invagination  and  strangulation,  typhlitis,  appendicitis, 
abscess,  carcinoma  and  echinoeoccus  of  the  liver,  absce.ss,  carci- 
noma, echinococcus  and  infarction  of  the  spleen,  abscess  and 
embolism  of  the  kidney,  paranephritis,  impacted  renal  or  biliary 
calculi,  metritis,  salpingitis,  oophoritis,  cystitis,  prostatitis,  strangu- 
lated hernia,  suppurating  inguinal  glands,  burrowing  abscesses  of 
the  vertebrae,  pleuritis,  pericarditis,  etc.  These  and  similar  dis- 
eases may  cause  peritonitis  by  rupture  and  evacuation  into  the 
abdominal  cavity  of  material  capable  of  exciting  inflammation. 
Such  a  condition  is  designated  perforative  peritonitis. 

At  times  peritonitis  develops  in  the  course  of  infectious  dis- 
eases, as,  for  instance,  septicopyemia,  erysipelas,  fibrinous  pneu- 
monia, typhus  fever,  and  the  like.  Without  doubt  morbid  altera- 
tions in  the  bodily  metabolism  diminish  the  resistance  of  the  peri- 
toneum, and  increase  its  susceptibility  to  inflammation.  Among 
such  disorders  are  uremia,  pulmonary  tuberculosis,  the  carcino- 
matous cachexia,  and  scorbutus.  Feritonitis  may  be  superadded 
to  other  diseases  of  the  peritoneum,  particularly  tuberculosis  and 
carcinoma.  There  are,  however,  cases  in  which  no  cause  for  the 
inflammation  can  be  demonstrated — cryptogenetic  peritonitis.  The 
condition  under  such  circumstances  may  often  be  an  alimentary 
'peritonitis,  by  which  it  is  understood  that  bacteria  migrate  from 
the  intestinal  contents  through  the  intestinal  wall  into  the  peri- 
toneal cavity  and  give  rise  to  inflammation.  Not  at  all  rarely  the 
statement  is  positively  made  that  the  symptoms  of  peritonitis  have 
rapidly  developed  in  the  sequence  of  errors  in  diet  (the  ingestion 
of  cold  or  spoiled  beer,  or  of  unripe  fruit). 

Peritonitis  may  occur  at  any  period  of  life ;  it  may  develop 
even  in  the  newborn  in  the  sequence  of  septic  infection  of  the 
umbilical  wound.  At  times  children  are  born  with  chronic  syph- 
ilitic peritonitis.  Peritonitis  is  most  common,  naturally,  between 
the  fifteenth  and  the  forty-fifth  year  of  life.  Women  are  attacked 
more  commonly  than  men,  because  diseases  of  the  female  genera- 
tive apparatus  often  constitute  the  source  for  inflammation  of  the 
peritoneum. 

Anatomic  Alterations. — Inflammatory  processes  in  the 
peritoneum  pursue  much  the  same  course  as  inflammatory  pro- 
cesses in  other  serous  membranes,  and,  accordingly,  a  differentia- 


374  DIGESTIVE  ORGANS 

tion  has  been  made  between  fibrinous,  serous,  purulent,  and  hemor- 
rhagic peritonitis.  In  addition  there  occurs  putrid  peritonitis, 
which  results  from  a  j)urulent  peritonitis  when  the  purulent  exu- 
date becomes  infected  with  the  bacteria  of  putrefaction.  Often 
mixed  varieties  of  peritonitis  occur,  which  may  be  designated  sero- 
fibrinous, tibrinopurulent,  etc.,  respectively.  In  accordance  with 
the  extent  of  the  inflammation  of  the  peritoneum  a  distinction  is 
made  between  circamscribed  (localized)  and  diffuse  jjeritonitis. 
Further  reference  to  circumscribed  peritonitis  will  not  be  made 
here,  because  this  is  considered  in  other  places  as  perityphlitis, 
perinepliritis,  perihepatitis,  perisplenitis,  etc. 

Fibrinoits  peritonitis  is  characterized  by  viyid  redness  and 
over-distention  of  the  diseased  peritoneum  with  blood.  Here 
and  there  individual  blood-vessels  have  ruptured,  and  punctate 
and  sometimes  larger  extravasations  of  blood  have  taken  place. 
Soon  swelling,  fatty  degeneration,  and  desquamation  of  the  endo- 
thelial cells  of  the  peritoneum  take  place,  and  the  serous  mem- 
brane in  these  situation  appears  turbid  and  dull,  like  a  plate  of 
glass  that  has  been  breathed  upon.  The  alterations  in  the  endo- 
thelium render  it  possible  for  the  exudate  from  the  blood-vessels 
— containing  considerable  fibrin — to  coagulate  upon  the  surface  of 
the  peritoneum,  and  to  form  at  first  thin,  cob-web  like,  and  sub- 
sequently thicker,  yellow,  and  opaque  deposits.  Through  these 
fibrinous  membranes  numerous  adhesions  take  place  between  the 
abdominal  viscera,  particularly  loops  of  intestine.  Should  the 
process  terminate  in  recovery,  the  fibrinous  exudate  may  be 
entirely  absorbed  and  disappear.  ]\Iore  commonly,  it  is  true,  the 
exudate  is  more  or  less  extensively  transformed  into  connective 
tissue,  which  forms  peritoneal  bands  and  adhesions  between  the 
individual  abdominal  viscera.  At  tiiues  the  entire  mass  of  intes- 
tine and  the  remaining  abdominal  viscera  are  so  firmly  bound 
together  that  the  whole  constitutes  an  inseparable  convolution, 
and  the  abdominal  cavity  is  completely  obliterated — obliterative 
peritonitis. 

Serous  peritonitis  is  attended  with  an  accumulation  of  slightly 
turbid,  yellowish  or  yellowish-green  fluid  in  the  abdominal  cavity. 
As  a  rule,  the  fluid  contains  flocculi  of  fibrin,  and  also  the  intes- 
tines and  the  remaining  abdominal  viscera  are  covered  with  fibrin- 
ous masses,  so  tliat  the  condition  generally  becomes  one  of  sero- 
fibrinous peritonitis.  Purulent  infleomadtion  of  the  peritoneum — 
suppurcdive  peritonitis — occurs  far  more  commonly  than  serous 
peritonitis,  and  this  fact  is  probably  indicative  of  the  greater  irri- 
tability of  the  peritoneum  in  comparison  with  some  other  serous 
membranes  (pleura,  pericardium).  The  peritoneum  is  rather  com- 
parable with  the  meninges  in  this  connection.  The  pus  in  the  ab- 
dominal cavity  presents  the  usual  ai)}iearance,  and  it  often  reaches 
several  quarts  in  amount.     It  becomes  especially  abundant  in  the 


INFLAMMATION  OF  THE  PERITONEUM  375 

true  pelvis.  In  addition  to  pus  fibrinous  deposits  are  also  encoun- 
tered, and  these  often  bind  the  loops  of  intestine  together.  If 
adhesions  are  separated,  deep  pockets  are  often  exposed  filled  with 
pus.  Should  absorption  of  the  pus  take  place  in  the  further  course 
of  the  curative  process,  fibrinous  deposits  remain  and  subsequently 
undergo  the  same  changes  that  have  been  described  for  fibrinous 
peritonitis.  Putrid  j^^^^iiomtis  is  characterized  by  the  offensive 
odor  of  the  pus,  being  irritating  to  both  the  nostrils  and  the  eyes. 
The  putrid  material  causes  irritation  of  the  skin  of  the  dissector. 
On  microscopic  examination  of  the  pus  the  pus-corpuscles  are 
found  in  a  state  of  partial  degeneration.  The  pus  contains  in- 
numerable bacteria.  Putrid  peritonitis  occurs,  in  addition  to  sep- 
ticopyemia, particularly  in  the  sequence  of  rupture  of  the  abdominal 
viscera.  If  the  ruptured  organ  is  a  gas-containing  viscus  (esoph- 
agus, stomach,  intestine),  gas  frequently  escapes  into  the  abdominal 
cavity,  and  the  condition  is  designated  pnewnoperitonitis.  Hemor- 
rhagic 'peritonitis  occurs  in  connection  with  tuberculosis  and  car- 
cinoma of  the  peritoneum,  nephritis,  and  scorbutus. 

Symptoms  and  Diagnosis. — The  symptoms  of  peritonitis 
vary  in  accordance  with  the  nature  of  the  inflammation.  An 
account  of  the  symptoms  of  diffuse,  acute,  purulent  peritonitis, 
perforative  peritonitis,  and  chronic  peritonitis  follows  : 

Symptoms  of  Acute,  Diffuse,  Purulent  Peritonitis. — A  constant 
symptom  of  acute,  diffuse,  purulent  peritonitis  is  pain.  At  first 
this  may  be  purely  local  in  the  situation  of  the  organ  from  which 
the  inflammation  of  the  peritoneum  has  originated,  but  soon  it 
extends  over  the  entire  abdomen,  and  increases  in  such  degree  that 
the  gentlest  manipulation  of  the  abdominal  walls  and  the  slight 
pressure  of  a  thin  sheet  cannot  be  borne.  The  patient  avoids 
speaking  in  a  loud  tone,  deep  breathing,  or  change  in  posture,  in 
order  to  prevent  aggravation  of  the  pain.  Not  rarely,  in  spite  of 
all  precautions,  the  pain  exhibits  paroxysmal  and  colicky  increase 
in  severity,  and  this  is  frequently  associated  with  audible  gurgling 
in  the  abdomen  and  increased  intestinal  movement. 

The  abdomen  is  distended  like  a  drum  and  at  times  to  the  point 
of  rupture,  the  overlying  skin  being  glistening  and  smooth.  The 
cause  for  this  condition  consists  in  marked  distention  of  the  intestine 
with  gas— intestinal  meteorism — and  this  in  turn  is  dependent  upon 
disturbed  intestinal  digestion  and  abnormal  fermentation  of  the  in- 
testinal contents.  On  percussion  of  the  abdomen  a  uniformly  loud 
tympanitic  percussion-note  is  not  rarely  audible  everywhere.  In 
other  instances  areas  of  dulness  appear  in  irregular  distribution,  in 
correspondence  with  accumulations  of  fluid  exudate.  Such  dul- 
ness is  most  common  in  the  dependent  and  lateral  portions  of  the 
abdomen.  Displacement  of  dulness  with  change  in  posture  is 
scarcely  observed,  as  the  exudate  is  usually  confined  within  cir- 
cumscribed cavities.     As  a  rule,  fluctuation  cannot  be  elicited  at 


376  DIGESTIVE  ORGANS 

all  over  exudatos,  or  but  imperfectly.  In'  accordance  with  the 
degree  of  rueteorism  the  diaphragm,  the  lower  borders  of  the 
lungs,  and  the  heart  are  greatly  displaced  upward.  The  patient, 
therefore,  complains  frequently  of  dyspnea,  a  sense  o^  fear,  of 
oppres-non,  and  of  palpitation  of  the  heart. 

Vomiting  usually  occurs  in  consequence  of  irritation  of  the 
stomach.  The  vomited  matter  consists  at  first  of  the  gastric 
contents,  and  its  apj>earance  accordingly  varies  with  accidental 
conditions  ;  but  later  it  frequently  presents  a  greenish,  bilious 
appearauce.  With  progressive  exhaustion  the  vomiting  ceases, 
and  it  is  often  replaced  by  troublesome  eructation  or  singultus. 
Thirst  is  greatly  increased,  whereas  the  appetite  is  completely 
wanting.  The  tongue  is  often  coated,  but  in  other  instances 
it  presents  a  clean  and  strikingly  red  appearance,  usually  in 
consequence  of  frequent  vomiting  and  slight  irritation  of  its 
mucous  membrane.  At  times  the  6/"fa//i!  is  offensive.  At  the  begin- 
ning of  the  disease  the  stools  are  generally  thin  and  liquid,  but 
subsequently  marked  constipation  commonly  exists.  The  urine 
is  usually  voided  in  diminished  amount.  The  secretion  is  generally 
dark  red  (high-colored,  saturated),  frequently  precipitates  a  brick- 
dust  sediment,  and  contains  much  indican  in  consequence  of  de- 
rangement of  intestinal  digestion  and  increased  decomposition 
of  proteids  in  the  intestine.  Slight  albuminuria  also  is  not  a  rare 
occurrence.  At  times  the  patients  complain  of  pain  in  the  evacu- 
ation of  urine  and  of  retention  of  urine,  svmptoms  that  are  often 
associated  w-ith  pericystitis. 

The  hofJUy  temperature  is  elevated  at  times  as  high  as  40°  C. 
(104°  F.)  and  above,  although  the  course  of  the  fever  is  irregular. 
Pulse  and  respiration  are  frequently  more  greatly  accelerated  than 
the  height  of  the  fever  warrants,  because,  in  addition  to  the  eleva- 
tion of  temperature,  displacement  of  the  lungs  and  of  the  heart 
and  nervous  influences  are  operative.  The  rapidity  and  the 
severitv  with  which  the  general  condition  suffers  are  noteworthy. 
The  facial  expression  is  painful  and  the  features  are  distorted,  the 
eyes  become  deeply  sunken  and  surrounded  by  blue  lines,  and  the 
chin  and  nose  become  sharply  prominent. 

The  course  of  acute  diffuse  j^^/'ifonitis  may  terminate  fatally 
within  a  few  days  amid  septic  manifestations  and  progressive  as- 
thenia, while  in  other  instances  the  disease  is  prolonged  for  weeks 
and  even  for  months,  with  numerous  fluctuations,  pursuing  rather  a 
subacute  and  even  a  chronic  course.  Often  the  outlook  for  recov- 
ery- appears  most  promising,  but  a  renewed  turn  for  the  worse 
rapidly  dispels  hope.  Among  complications  symptoms  of  ileus  may 
be  mentioned  first,  and  amid  which  death  may  take  place  without 
mechanical  obstruction  of  the  l>owel  being  found  upon  post-mortem 
examination.  The  condition  is  therefore  designated  dynamic  ileus, 
resulting  from   local  paralysis  of  the  musculature  of  the  bowel. 


INFLAMMATION  OF  THE  PERITONEUM  377 

At  times  metastatic  inflammatory  processes  appear  in  other  situ- 
ations ;  most  commonly  in  the  right  pleural  cavity,  and  at  times 
also  in  the  pericardial  cavity.  Under  such  circumstances  it  is 
often  remarkable  within  how  short  a  time  a  pleuritic  effusion  may 
be  again  completely  absorbed  when  the  peritonitis  shows  a  dispo- 
sition toward  improvement.  Particularly  serious  are  crrcumscribed 
collections  of  pus,  which  form  especially  between  the  loops  of 
bowel.  In  the  first  place,  they  may  readily  give  rise  to  renewed 
exacerbations  of  the  peritoneal  inflammation ;  and  besides,  they 
may  rupture  into  adjacent  organs,  as,  for  instance,  into  the  intes- 
tine, the  stomach,  the  genito-urinary  passages,  through  the  abdom- 
inal walls,  and  particularly  through  the  umbilicus.  Although 
natural  recovery  may  follow  such  an  accident,  it  is  also  possible 
for  the  pus  to  become  infected  with  fecal  matter  or  with  urine  and 
become  putrid,  and  in  this  way  cause  death  by  septicopyemia. 
Rupture  of  pus  into  the  large  blood-vessels  of  the  abdominal 
cavity  is  dangerous,  for  in  addition  to  hemorrhage  general  septi- 
cemia may  occur.  Also  when,  contrary  to  experience,  absorption 
of  pus  takes  place,  serious  sequelce  at  times  develop.  The  bowel 
may  be  so  greatly  displaced  and  distorted  in  consequence  of 
peritoneal  adhesions  that  stenosis  and  even  obstruction — ileus — 
result.  Similar  conditions  may  also  be  brought  about  by  loops 
of  intestine  slipping  beneath  peritonitic  bands  or  being  surrounded 
by  them. 

Symptoms  of  Perforative  Peritonitis. — The  symptoms  of  per- 
forative peritonitis  depend  upon  whether  the  inflammation  of 
the  peritoneum  is  free  or  encapsulated,  and  whether  the  rup- 
ture has  taken  place  from  a  gas-containing  or  an  airless  viscus. 
In  case  of  rupture  of  the  stomach,  the  intestine,  or  the  esophagus, 
in  addition  to  particles  of  food,  gas  usually  escapes  into  the  ab- 
dominal cavity,  and  accordingly  there  develops  a  free  or  a  saccu- 
lated pneumoperitonitis.  With  the  development  of  a  free  pneumo- 
peritonitis  the  patient  not  rarely  cries  aloud  that  something  has 
torn  within  the  abdominal  cavity,  and  he  complains  generally  of 
indescribable  pain  in  the  abdomen.  The  abdominal  walls  are  re- 
tracted, stretched  with  board-like  hardness,  and  exceedingly  tender 
to  touch.  It  is  noteworthy  that  outlines  of  loop.s  of  intestine  beneath 
the  abdominal  walls  are  not  visible,  and  that  also  no  peristaltic 
movement  of  the  bowel  can  be  detected.  Of  particularly  great 
diagnostic  significance  is  the  disappearance  of  the  hepatic  and  the 
splenic  dulness,  which  results  in  consequence  of  the  rise  of  the  escap- 
ing air  and  the  displacement  of  the  liver  and  the  spleen  from  the 
thoracic  and  abdominal  walls.  This  important  sign  will  be  absent 
only  when  the  liver  and  the  spleen  have  previously  been  immov- 
ably bound  by  peritoneal  adhesions  to  the  thoracic  and  abdominal 
walls.  Frequently  vomiting  occurs,  although  its  absence  has  been 
observed  in  case  of  rupture  of  the  stomach,  because  at  times  in 


378  DIGESTIVE  ORGANS 

the  efforts  at  vomiting  the  contents  of  the  stomach  pass  more 
readily  through  the  site  of  rupture  into  the  abdominal  cavity. 
The  general  condition  is  characterized  in  an  unmistakahle  man- 
ner by  tiie  signs  of  most  profound  exhaustion.  The  skin  feels 
cool,  the  pulse  is  small  and  running,  the  voice  is  faint  and  hoarse, 
the  face  is  pale,  the  eyes  are  sunken,  retracted,  and  surrounded 
by  gray  rings,  and  the  nose,  tlie  malar  bones,  and  the  chin  stand 
out  prominently.  Consciousness  is  preserved.  Death  may  result 
from  putrid  infection  and  progressive  exhaustion  within  a  few 
hours.  At  times  it  occurs  as  the  result  of  asphyxia  if  the  dia- 
phragm, the  lungs,  and  the  heart  are  displaced  upward  excessively 
in  consequence  of  intestinal  and  peritoneal  meteorism.  Recovery 
as  a  result  of  internal  medication  and  expectancy  occurs  most 
rarely,  but  life  has  been  saved  in  a  number  of  instances  of  late 
by  surgical  intervention. 

Sacculated  pneiuno peritonitis  occurs  especially  in  connection 
with  ulceration  of  the  stomach  and  the  intestine,  when  rupture 
of  these  viscera  has  been  preceded  by  circumscribed  peritonitis 
with  adhesions,  so  that  the  escape  of  gastric  or  intestinal  con- 
tents takes  place  into  the  previously  closed  cavity.  The  con- 
dition is  exceedingly  difficult  of  recognition.  Circumscribed 
tenderness  in  tlie  abdominal  cavity  should  be  looked  for.  Over 
this  area  a  dull  note  will  be  elicited  on  percussion,  in  so  far  as 
the  exudate  is  in  contact  with  the  abdominal  walls,  whereas  a 
tympanitic  percussion-note  will  be  obtained  over  the  gas-con- 
taining cavity.  The  fact  is  of  especial  importance  if  displacement 
of  the  percussion-boundaries  in  accordance  with  the  position  of 
the  body  can  be  demonstrated,  under  which  conditions  the  tym- 
panitic percussion-note  will  always  correspond  with  the  highest 
point  of  the  gas-containing  cavity.  It  may  also  be  possible  that 
vigorous  agitation  of  the  body  will  elicit  a  sue cussi on-sound  or  a 
splashing  sound,  although  there  will  be  some  hesitation  in  subject- 
ing the  patient  to  such  active  manipulation.  The  formation  of  a 
sacculated  pneumoperitonitis  may  take  place  so  insidiously,  as,  for 
instance,  in  a  case  of  typhoid  fever,  that  even  when  the  condition 
of  the  patient  is  most  carefully  followed  the  presence  of  the  dis- 
ease may  perhaps  be  recognized  only  at  the  autopsy.  The  subject 
of  subphrenic  pyopneumothorax  has  been  considered  on  p.  167. 

If  an  airless  viscus  has  ruptured  into  tlie  peritoneal  cavity 
(abscess  of  the  liver  or  of  the  spleen,  softened  lymphatic  glands, 
paranephritis,  burrowing  abscesses,  and  the  like),  or  if  an  air- 
containing  viscus  has  ruptured,  and  gas  has  accidentally  not  es- 
caped into  the  abdominal  cavity,  an  acute  diffuse  peritonitis  de- 
velops within  the  shortest  possible  time,  if  free  rupture  has  taken 
place  into  the  abdominal  cavity.  That  the  condition  is  one  of 
perforative  peritonitis  will  be  indicated  by  the  fact  that  tlie  patients 
often  designate  with  absolute  positiveness  a  circumscribed  area 


INFLAMMATION  OF  THE  PERITONEUM  379 

as  the  source  of  their  trouble,  and  that  not  rarely  also  in  the 
further  course  of  the  disease  definite  local  disturbances  become 
more  pronounced  in  this  situation,  as,  for  instance,  increased  ten- 
derness and  greater  accumulation  of  exudate. 

Sacculated  perforative  peritonitis  will  be  recognized  from  the 
presence  beneath  the  abdominal  walls  of  circumscribed  dulness, 
which  yields  increased  resistance  and  pain  on  palpation.  As  the 
condition  may  develop  quite  insidiously,  it  at  times  escapes  diag- 
nosis. Occasionally  it  is  recognized  only  from  the  sequelae,  if 
rupture  of  the  encapsulated  pus  takes  place  through  the  abdom- 
inal walls  or  into  intestinal   viscera. 

Symptoms  of  Clironic  Peritonitis. — Among  the  chronic  varie- 
ties of  peritonitis  peculiar  clinical  interest  attaches  to  that 
which  is  attended  Avith  the  formation  of  a  serous,  freely  movable 
accumulation  of  fluid  in  the  abdominal  cavity — chronic-serous 
peritonitis.  Usually  without  obvious  cause  more  and  more  fluid 
gradually  accumulates  in  the  abdominal  cavity.  The  abdomen 
increases  progressively  in  size.  Fluctuation  can  be  elicited,  and 
on  percussion  in  the  dorsal  decubitus  a  tympanitic  note  is  obtained 
over  the  upper  portion  of  the  abdomen  corresponding  to  the  loops 
of  intestine  floating  upon  the  fluid,  with  dulness  in  the  lateral 
portions.  Change  in  jjosition  is  followed  by  displacement  of  the 
percutory  phenomena,  the  uppermost  portion  of  the  abdomen 
yielding  a  tympanitic  percussion-note,  while  a  dull  note  is  ob- 
tained over  the  lowermost  portion.  The  intestines  always  tend 
to  rise  to  the  surface  of  the  fluid.  The  physical  phenomena  are, 
on  the  whole,  the  same  as  those  that  attend  ascites.  Differen- 
tiation from  ascites  is  possible  only  from  the  fact  that  causes  for 
this  condition  are  not  demonstrable,  and  that  the  inflammatory 
fluid  is  characterized  by  the  jiresence  of  a  greater  amount  of  albu- 
min (more  than  4  per  cent.)  and  a  higher  specific  gravity  (above 
1014).  Also  tenderness  of  the  abdominal  walls  and  transient 
febrile  movement  are  indicative  of  serous  peritonitis.  The  dif- 
ferentiation from  tuberculous-serous  peritonitis  is  far  more  difficult. 
In  favor  of  the  latter  disease  would  be  the  presence  of  tubercu- 
losis in  other  organs  (particularly  the  intestine,  the  lungs,  the 
lymphatic  glands,  the  kidneys,  the  epididymis,  the  urinary  pass- 
ages), or  the  detection  of  the  thickened  tuberculous  omentum  as 
a  dense  band  passing  transversely  across  the  abdominal  cavity. 
Even  after  the  abdomen  has  been  opened  the  diagnosis  may  still 
be  doubtful,  because  at  times  nodular  fibrous  thickenings  form 
upon  the  peritoneum  in  cases  of  chronic-serous  peritonitis,  pre- 
senting exactly  the  appearance  of  tubercles,  and  only  differing 
from  these  histologically  and  bacteriologically.  Chronic-serous 
peritonitis  may  pursue  an  afebrile  course,  and  not  rarely  causes 
no  other  pain  than  that  due  to  tension.  Should  the  effiision  of 
fluid  be  considerable,  dyspnea  and  acceleration  of  cardiac  action 


380  DIGESTIVE  ORGANS 

occur  in  consequence  of  displacement  of  the  diaphragm,  the  lungs, 
and  the  iieart.  The  disease  not  rarely  extends  over  many  months, 
undergoes  exacerbations  and  remissions,  and  is  susceptible  of  cure. 

Prognosis. — The  prognosis  of  all  varieties  of  peritonitis  is 
serious.  Acute  and  perforative  peritonitis  must  l)e  considered 
particularly  dangerous  diseases,  frequently  causing  death  from 
exhaustion  and  septicemia,  although  the  outlook  for  recovery  has 
recently  been  improved  in  some  varieties  by  surgical  treatment. 

Treatment. — The  treatment  of  peritonitis  depends  upon  the 
variety  of  irijiainmation.  In  cases  of  acute,  diffuse,  purulent  peri- 
tonitis the  patient  should  be  advised  to  observe  as  complete  rest 
as  possible,  and  invariably  to  use  a  bed-pan  in  the  evacuation  of 
the  bladder  and  the  bowels.  The  diet  should  be  liquid  and  con- 
sist preferably  of  milk,  coffee  with  milk,  tea  with  milk,  beef- 
soup,  and  wine  diluted  half  with  Avater.  For  the  relief  of  the 
severe  thirst,  and  in  the  presence  of  violent  vomiting,  small  bits 
of  ice  may  be  sucked.  For  the  inflammatory  alterations  in  the 
abdominal  cavity,  not  too  heavy  ice-bags  should  be  applied  to  the 
abdomen.  When  the  acute  inflammatory  .symptoms  n)oderate  the 
ice-bag  should  be  replaced  by  hot  cataplasms,  which  are  more 
agreeable  to  most  patients,  and  favor  al^sorption  of  the  effusion. 
Severe  localized  pain  in  the  abdomen  not  rarely  subsides  speedily 
after  the  application  of  from  5  to  10  leeches  to  the  abdomen. 
Among  internal  remedies  the  use  of  opium  or  morphin  may  be 
recommended  : 

B  Powdered  opium,  0.03  (J  grain), 

Sugar,  0.3  (4|  grains).— M. 

Make  10  such  powders. 
Dose:  1  powder  every  two  hours. 

R   Morphin  hydrochlorate,  0.3  (4^  grains)  ; 

Glycerin, 

Distilled  water,  each,  5.0  (75  minims). — M. 

Dose:  0.5  (8  minims)  once  or  twice  daily  injected  subcutaneously. 

Both  morphin  and  opium  are  employed  to  place  the  bowel  at 
rest.  As  a  result  the  pain  becomes  less,  and,  besides,  dissemina- 
tion of  the  pus  throughout  the  entire  abdominal  cavity  is  pre- 
vented. Some  patients  do  not  bear  o])ium  well,  and  develop 
.severe  pain,  nausea,  and  delirium  after  its  use,  and  for  these  mor- 
phin is  better  adapted.  Opium  or  morphin  shoidd  be  given  until 
the  abdomen  becomes  entirely  free  from  pain  on  pressure.  ]Many 
weeks  may  be  required  to  attain  this  end.  Should  improvement 
in  the  con<lition  take  place,  the  greatest  care  must  be  taken  with 
regard  to  the  diet  and  to  getting  up. 

The  treatment  o^ perforative  peritonitis  is  the  same  as  that  just 
described   in   so  far  as  internal    measures   are   applicable.      On 


INFLAMMATION  OF  THE  PERITONEUM  381 

account  of  the  alarming  loss  of  strength  it  will  be  necessary  to 
make  frequent  use  of  stimulants,  as,  for  instance  : 

R   Camphorated  oil,  10.0  (2^  fluidrams). 

Dose:  1.0  (15  minims)  subcutaneously  from  three  to  six  times  daily. 

If  the  perforation  has  involved  the  esophagus  or  the  stomach, 
the  introduction  of  all  food  or  drink  through  the  mouth  should  be 
interdicted,  and  the  administration  of  nourishment  be  confined  to 
rectal  enemata  of  milk,  meat-soup,  and  eggs  (p.  197).  Although 
internal  treatment  of  perforative  peritonitis  affords  only  slight 
hope  of  recovery,  it  has  been  possible  of  late  to  bring  this  about 
in  numerous  cases  through  surgical  treatment.  The  earlier  opera- 
tion is  undertaken  and  the  fewer  the  symptoms  of  general  septice- 
mia present  the  more  successful  w  ill  be  the  result.  The  operation 
generally  consists  in  abdominal  section — celiotomy — freeing  the 
abdominal  cavity  and  the  abdominal  viscera  from  the  matters  that 
have  escaped  through  the  perforation  by  careful  sponging,  and 
closure  of  the  line  of  rupture  by  suture.  At  times  it  is  necessary 
in  the  presence  of  ulcerative  processes  in  the  stomach  or  the  bowel 
to  precede  suture  by  excision  of  the  ulcer,  or  even  by  resection  of 
portions  of  either  viscus. 

In  a  case  of  ckronic-ser.ous  peritonitis  a  milk-diet  should  be  pre- 
scribed (from  1^  to  2  quarts  of  boiled  milk,  to  be  swallowed  in 
small  amounts  at  short  intervals),  as  this  not  rarely  stimulates 
active  diuresis  and  thereby  favors  absorption  of  the  exudate. 
Locally  I  have  observed  good  results  in  a  number  of  instances 
from  inunction  of  the  abdominal  walls  with  green  soap.  Among 
diuretics,  calomel,  diuretin,  and  preparations  of  caffein  are  particu- 
larly worthy  of  trial,  while  I  have  rarely  observed  good  results 
from  the  use  of  urea : 

B   Mercurous  chlorid, 

Sugar,  each,  0.3  (42-  grains). — M. 

Make  10  such  powders. 
Dose :  1  powder  thrice  daily. 

R   Diuretin,  1.0  (15  grains) ; 

Sugar,  0.5  (7*      "     ).— M. 

Make  10  such  powders. 
Dose :  1  powder  every  three  hours. 

R    Caffein  sodio-salicylate,  1.0  (15  grains) ; 

Sugar,  0.5  (7J      "     ).— M. 

Make  10  such  powders. 
Dose:  1  powder  thrice  daily. 

When  calomel  is  used  the  mouth  should  be  rinsed  with  potas- 
sium chlorate  (10.0:200 — 2^  drams  :  6^  fluidounces)  after  each 
meal  in  order  to  prevent  the  development  of  mercurial  stomatitis. 
Diaphoretics  are  also  worthy  of  trial ;  as,  for  instance,  hot-air  baths 
by  means  of  a  siveating  chamber,  and  subcutaneous  injections  of 
pilocarpin  hydrochlorate. 


382  DIGESTIVE  ORGANS 

R    Solution  of  pilocarpin  hydrochlorate,  0.2  :  10.0 

(3  grains  :  2.}  fluidrams). 
Dose :  0.5  (8  minims)  .subcutaneously. 

The  use  of  purgatives  and  drastics  should  be  abstained  from. 
Should  there  be  danger  of  suffocation  from  excessive  accumulation 
of  fluid,  puncture  or  incision  of  the  abdomen  should  be  practised, 
but  not  rarely  fluid  reaccumulates. 

ABDOMINAL  DROPSY  (ASaTES), 

Ktiology. — Ascites  consists  in  a  collection  of  serous  fluid  in 
the  peritouiial  cavity,  not  resulting  from  inflammatory  processes, 
but  dependent  upon  purely  physical  causes.  The  fluid  is  not  an 
exudate,  but  a  transudate.  Two  modes  of  origin  for  such  a  trans- 
udate are  recognized  :  namely,  increased  blood-pressure  in  the  veins 
and  abnormal  permeability  of  the  walls  of  the  veins.  Accordingly, 
a  distinction  is  made  between  Jiijpostatic  ascites  under  the  first  con- 
ditions and  cachectic  ascites  under  the  second.  Hypostatic  ascites 
either  is  a  result  of  general  venous  stasis  in  connection  with 
chronic  disease  of  the  heart  or  the  respiratory  organs,  or  it  is  due 
rather  to  local  causes  and  develops  in  consequence  of  portal  stasis. 
The  last-named  condition  arises  most  commonly  in  connection  with 
chronic  interstitial  hepatitis,  and  less  commonly  in  connection  with 
other  diseases  of  the  liver  (carcinoma,  abscess,  echinococcus),  with 
pvletlu'ombosis  and  obstruction  of  the  portal  vein  by  adjacent 
tumors,  lymphatic  glands,  and  the  like.  Rarely  stenosis  of  the 
hepatic  veins  constitutes  a  cause  for  hypostatic  ascites.  Cachectic 
ascites  occurs  most  commonly  in  association  with  nephritis,  although 
it  attends  also  carcinoma,  pulmonary  tuberculosis,  chronic  suppu- 
ration, chronic  diarrhea,  and  all  debilitating  conditions.  Ascites 
occurs  at  all  periods  of  life.  It  may  develop  during  fetal  life  in 
consequence  of  hereditaiy  syphilis,  and  cause  obstruction  in  labor. 
Most  commonly  it  is  observed  after  the  twentieth  year  of  life,  as  a 
large  number  of  its  causes  first  become  operative  at  about  this 
time. 

Anatomic  Alterations. — Extensive  ascites  gives  rise  to  dis- 
tention of  the  abdomen,  while  smaller  accumulations  of  fluid,  on 
the  other  hand,  collect  first  in  tlie  true  pelvis.  Under  the  cinidi- 
tions  first  named  the  fluid  often  escapes  in  a  powerful  stream  when 
the  abdomen  is  opened,  as  the  amount  of  fluid  may  exceed  twenty 
quarts.  As  a  rule,  the  fluid  is  greenish  yellow  in  appearance, 
seldom  bloody,  but  in  the  presence  of  jaundice  it  contains  biliary 
coloring-matter.  The  fluid  is  transparent  and  clear,  and  contains 
at  most  a  few  grayish  floceuli  of  detached  endothelial  cells  involved 
in  fatty  degeneration,  and  soft  gelatinous  coagula,  which  may  after 
a  time  undergo  solution  again.  At  times  glistening  crystals  of 
cholesterin  are  present.     Tiie  reaction  of  the  fluid  is  alkaline,  and 


ABDOMINAL  DROPSY  383 

its  specific  gravity  fluctuates  between  1004  and  1014.  "When  ascites 
has  existed  for  some  time  the  abdominal  organs  with  which  the 
fluid  comes  in  contact  often  appear  pale  and  macerated. 

Fatti/  ascites  and  chylous  ascites  have  further  been  described.  Fatty 
ascites  were  better  designated  fatty  peritonitis.  It  develops  at  times  in 
cases  of  tuberculosis  or  carcinoma  of  the  peritoneum,  when  a  considerable 
number  of  fattily  degenerated  cells  are  thrown  off  by  the  tuberculous  nodules 
or  the  carcinomatous  new-growth,  and  become  in  part  admixed  with  the 
peritoneal  exudate  and  in  part  dissolved  therein.  The  fluid  presents  a  milky, 
opaque  appearance,  and  a  layer  of  fat  forms  upon  its  surface  upon  standing. 
Chylous  ascites  likewise  is  attended  with  fluid  of  milky  appearance,  but  this 
results  from  admixture  with  chyle,  which  is  derived  from  ruptured  lacteals. 
In  contradistinction  from  fatty  ascites,  the  chylous  fluid  contains  sugar. 
The  condition  is  most  common  in  association  with  carcinoma  of  abdominal 
viscera. 

Symptoms  and  Diagnosis. — The  principal  symptom  of 
ascites  consists  in  the  presence  of  a  free,  movable  accumulation  of 
fluid  in  tlie  abdominal  cavity,  which,  in  contradistinction  from 
peritonitic  fluid,  has  developed  without  fever  and  without  note- 
worthy pain.  Transudation  of  considerable  amount  in  the  abdom- 
inal cavity  causes  increase  in  the  size  of  the  abdomen,  which  at 
times  attains  enormous  proportions.  The  anterior  aspect  of  the 
abdomen  appears  flattened,  while  the  lateral  aspects  are  particu- 
larly expanded.  In  the  erect  posture  the  fluid  accumulates  in  the 
lower  half  of  the  abdomen,  and  a  sort  of  pendulous  abdomen 
forms.  The  skin  of  the  abdomen  is  smooth  and  glistening,  and 
not  rarely  small  points  of  rupture  in  the  skin  occur  in  the  lower 
portions — so-called  strice — which  entirely  resemble  the  well-known 
cicatrices  of  pregnancy.  Upon  the  posterior  and  lateral  aspects 
of  the  abdomen  cutaneous  edema  not  rarely  develops,  and  it  may 
become  so  excessive  as  to  cause  rupture  of  the  skin,  with  escape 
of  fluid,  erythema,  erysipelas,  or  gangrene  of  the  skin,  and  at 
times  with  death  from  septicemia.  The  umbilicus  is  either  obliter- 
ated or  it  protrudes  like  a  hernia.  At  the  same  time  it  is  translu- 
cent in  transmitted  light,  an  indication  that  the  protrusion  contains 
fluid  that  has  found  its  way  out  of  the  abdominal  cavity  through 
the  patulous  and  palpable  umbilical  ring.  The  cutaneous  abdominal 
veins  are  usually  greatly  distended  and  markedly  tortuous,  obvi- 
ously because  of  compression  and  obstruction  of  the  ascending 
vena  cava  by  the  abdominal  fluid,  so  that  a  portion  of  the  venous 
blood  from  the  lower  extremities  must  find  its  way  to  the  heart 
through  the  veins  of  the  abdominal  wall.  The  demonstration  of 
fluctuation  is  extremely  important  from  a  diagnostic  point  of  view. 
The  percutory  phenomena  vary  with  the  position  of  the  body.  In 
the  dorsal  decubitus  a  tympanitic  note  will  be  developed  over  the 
upper  anterior  portions  of  the  abdomen,  and  a  dull  note  over  the 
lower  and  lateral  portions.  In  the  lateral  decubitus  the  dulness 
over  the  uppermost  side  disappears,  and  is  replaced  by  a  tympa- 


384  DIGESTIVE  ORGANS 

nitic  percussion-note.  The  lowermost  portion  of  the  abdomen,  on 
the  other  hand,  yields  a  dull  note  everywhere.  These  phenomena 
depend  upon  the  faet  that  the  intestines,  which  yield  a  tympanitic 
note,  constantly  have  a  tendency  to  float  upon  the  surface  of  the 
fluid. 

In  the  dorsal  decubitus  a  narrow,  longitudinal  band  with  a  tympanitic 
percussion-note  appears  not  rarely  in  the  posterior  and  lateral  portions,  cor- 
responding with  the  gas-containing  ascending  and  descending  colon.  The 
tympanitic  area  over  the  anterior  abdominal  wall  will  be  absent  in  associa- 
tion with  ascites  when  the  mesentery  is  short  with  relation  to  the  amount 
of  Huid  in  the  abdominal  cavity,  so  that  the  intestines  are  prevented  from 
floating  upon,  but  are  immersed  beneath,  the  surface  of  the  fluid.  Small 
accumulations  of  fluid  in  the  abdominal  cavity  that  have  collected  in  the 
true  pelvis  become  accessible  to  percussion  only  if  the  pelvis  is  elevated  or 
the  patient  assumes  the  prone  position.  Under  the  condition  first  named, 
if  the  fluid  enters  the  upper  portion  of  the  abdominal  cavity,  dulness  ap- 
pears upon  either  side  of  the  vertebral  column,  and  under  the  latter  condi- 
tion over  the  anterior  abdominal  wall. 

Extensive  ascites  may  occasion  alarming  dyspnea  by  displace- 
ment upward  of  the  diaphragm,  the  lungs,  and  the  heart,  and  all 
the  more  because  the  expansion  of  the  lungs  and  the  movements 
of  the  heart  are  often  interfered  with  in  consequence  of  associated 
hydrothorax  and  hydropericardium. 

We  have  hitherto  considered  only  ascites  free  in  the  abdominal  cavity. 
At  times,  however,  the  effusion  is  encapsulated  or  sacculated,  and  the  princi- 
pal symptom  then  is  circumscribed  dulness  and  fluctuation.  In  contradis- 
tinction from  circumscribed  peritonitis,  fever  and  pain  are  wanting. 

In  the  presence  of  general  causes  for  stasis  and  of  cachectic 
ascites,  cutaneous  edema,  hypostatic  urine,  and  often  also  hydro- 
thorax  and  hydropericardium  are  encountered.  Should  ascites 
exist  alone  and  without  edema  in  other  situations,  it  is  probably  of 
portal  origin.  If  the  ascites  by  reason  of  its  extent  exerts  con- 
siderable pressure  upon  the  inferior  vena  cava,  hypostatic  edema 
in  the  lower  extremities  may  eventually  develop,  but  in  compari- 
son with  large  abdominal  effusions  this  usually  attains  slight  pro- 
portions. Ascites  is  generally  a  chronic  disorder,  as  its  etiologic 
factors  are  of  a  chronic  nature.  Frequently  exacerbations  and 
remissions  alternate,  accordingly  as  the  strength  of  the  mus- 
cular structure  of  the  right  side  of  the  heart  and  in  connection 
therewith  the  stasis  in  the  distribution  of  the  inferior  vena  cava 
vary.  Death  from  suffocation  and  cardiac  paralysis  are  the  prin- 
cipal dangers. 

On  the  whole,  ascites  is  easily  and  certainly  recognized. 
Although  similar  physical  signs  are  yielded  also  by  chronic- serous 
and  tuberculous-serous  peritonitis,  stasis  or  cachexia  will,  in  the 
first  place,  usually  be  found  to  be  the  cause  of  ascites;  in  addi- 
tion, febrile  movement  and  marked  tenderness  of  the  abdomen 
are  wanting ;  and,  finally,  any  fluid  obtained  upon  puncture  will 


ABDOMINAL  DROPSY  385 

be  characterized  by  its  lower  specific  gravity  (below  1014) 
and  the  presence  of  a  small  amount  of  albumin  (less  than  4  per 
cent.).  Even  experienced  clinicians  have  in  numerous  instances 
confounded  ascites  with  an  ovarian  cyst.  In  the  differential  diag- 
nosis it  is  important  to  recall  that  the  anterior  abdominal  wall  is 
flattened  when  ascites  exists,  while  it  is  pushed  forward  by  an 
ovarian  cyst.  The  umbilicus  is  obliterated  in  the  presence  of 
ascites  or  it  protrudes  forward,  while  with  ovarian  cysts  it  remains 
unchanged,  or  is  even  displaced  upward.  With  ascites  the  lateral 
aspects  of  the  abdomen  are  dull  on  percussion  when  the  patient 
occupies  the  dorsal  decubitus,  while  the  anterior  portion  yields  a 
tympanitic  note.  The  conditions  are  reversed  when  an  ovarian 
cyst  is  present,  with  dulness  anteriorly  and  a  tympanitic  note 
laterally.  Variations  in  the  percussion-phenomena  in  accordance 
with  the  position  of  the  body  are  characteristic  of  ascites,  and  are 
w^anting  with  ovarian  cysts,  as  the  fluid  is  not  capable  of  free 
movement  in  the  cyst,  which  is  closed  upon  all  sides.  Although 
fluctuation  is  present  in  both  diseases,  it  is  confined  strictly  to  the 
area  of  dulness  with  ovarian  cysts,  while  with  ascites  it  is  appreci- 
able also  beyond  this  area.  With  ascites  the  uterus  is  often  dis- 
placed downward,  and  is  exceedingly  mobile,  in  consequence  of 
the  pressure  exerted  by  the  collection  of  fluid,  while  with  ovarian 
cysts  it  is  displaced  upward  or  laterally. 

If  fluid  be  obtained  for  examination  by  puncture,  it  will  be  found  in  the 
presence  of  ascites  to  present  a  lower  specific  gravity  (below  1014)  than  in 
that  of  an  ovarian  cyst  (above  1015  j,  and  that  with  the  latter  disease  the 
fluid  not  rarely  exhibits  a  gelatinous  consistency,  and  that,  finally,  on 
microscopic  examination  the  sediment  will  be  found  to  contain  squamous 
epithelial  cells  with  ascites,  while  with  ovarian  cysts  cylindric  eijithelial 
cells  are  present. 

Prognosis. — The  prognosis  of  ascites  depends  upon  the  possi- 
bility of  controlling  the  causes  of  the  disorder.  As  a  rule,  such 
control  can  be  acquired  temporarily  in  the  most  favorable  cases, 
but  ultimately  the  remedies  employed  fail,  and  the  patient  dies 
with  excessive  accumulation  of  fluid  in  the  abdominal  cavity  as  a 
result  of  asphyxia  or  cardiac  paralysis. 

Treatment. — The  treatment  of  ascites  should  be,  in  the  first 
place,  causal,  and  in  accordance  with  the  causative  factors  heart- 
tonics  (digitalis),  diuretics  (diuretin,  calomel,  urea),  drastics, 
diaphoretics,  or  stimulants  should  be  employed.  Among  measures 
of  local  treatment  only  one  is  trustworthy  and  to  be  recommended, 
namely,  abdominal  puncture,  while  faradization  of  the  abdominal 
wall,  inunctions  with  soft  soap,  abdominal  bandages,  and  the  like, 
are  unreliable.  As  abdominal  puncture  is  a  harmless  procedure, 
which  is  capable  of  affording  the  patient  great  relief,  the  custom 
is  properly  becoming  more  common  of  practising  it  early,  and  not 
reserving  it  as  a  last  resort.     As  often  as  the  fluid  reaccuraulates  in 

25 


386  DIGESTIVE  ORGANS 

troublesome  or  threatening;  degree  puneture  of  the  abdomen  should 
be  repeated.  In  rare  cases,  however,  reaccumulation  of  fluid  does 
not  take  place,  and  recovery  ensues. 

CARCINOMA  OF  THE  PERITONEUM. 

As  a  rule,  carcinoma  of  the  peritoneum  is  a  secondary  disorder , 
the  new-growth  extending  directly  from  involved  abdominal 
viscera  to  the  adjacent  peritoneum  or  discrete  metastasis  taking 
place.  At  times  the  peritoneum  is  strewn  with  innumerable  small 
nodules  suggestive  of  miliary  tubercles — miliary  carcinoma  of  the 
peritoneum;  or  extensive  carcinomatous  nodules  develop;  or, 
finally,  the  peritoneum  is  in  places  the  seat  of  carcinomatous  infil- 
tration. The  abdominal  cavity  generally  contains  inflammatory 
or  edematous  fluid,  which  may  be  serous,  but  is  frequently  bloody 
and  at  times  fatty  or  chylous. 

The  diagnosis  is  generally  based  upon  the  discovery  of  freely 
movable  fluid  in  the  abdominal  cavity  (fluctuation,  alterations  in 
the  peixnission-phenomena  with  change  in  posture),  and  upon  the 
conclusion  that  the  condition  is  of  carcinomatous  origin  from  the 
discovery  of  similar  disease  in  other  organs.  Should  abdominal 
puncture  be  practised,  the  bloody  appearance  of  the  fluid  obtained 
from  the  abdominal  cavity,  or  its  fatty  or  chylous  appearance, 
and  the  occurrence  of  numerous  fattily  degenerated  or  polynuclear 
cells,  will  be  noteworthy.  In  doubtful  cases  examination  should 
be  made  for  carcinomatous  induration  and  enlargement  of  peripheral 
lymphatic  glands,  particularly  in  the  groin  and  above  the  left 
clavicle. 

The  prognosis  is  unfavorable  and  the  treatment  purely 
symptomatic. 

ECHINOCOCCUS  OF  THE  PERITONEUM. 

Echinococcus  of  the  peritoneum  occurs  either  in  conjunction 
with  echinococcus  in  other  abdominal  viscera,  particularly  the 
liver,  or  in  the  peritoneum  alone.  Palpation  discloses  the  presence 
of  a  fluctuating  tumor,  over  which  at  times  also  hydatid  tremor 
can  be  felt.  Occasionally  innumerable  echinococcus-vesicles  are 
present  in  the  abdominal  cavity,  and  in  other  instances  but  a  single 
echinococcus-cyst  has  developed,  as,  for  instance,  in  the  omentum. 
In  the  latter  event  the  cyst  could  be  removed  by  surgical  means. 
The  principal  danger  consists  in  progressive  growth  and  asphyxia. 


PART  IV. 

DISEASES  OF  THE  GENITO-URINARY 

ORGANS. 


I.   DISEASES  OF  THE   KIDNEYS. 


DIAGNOSTIC  PRELIMINARY  CONSIDERATIONS. 

Most  diseases  of  the  kidneys  can  be  recognized  from  the 
alterations  in  the  urine  to  which  they  give  rise.  Only  rarely  are 
peculiarities  discovered  by  local  examination  of  the  kidneys. 
Among  the  nrinary  changes  the  character  of  the  sediment  (which 
is  best  obtained  by  means  of  a  centrifuge)  and  admixture  of 
albumin  or  of  blood — albuminuria  or  hematuria — are  the  most 
significant.  The  importance  of  the  two  phenomena  last  men- 
tioned will  justify  their  more  thorough  consideration.  A  descrip- 
tion of  uremia  will  be  added,  because  this  represents  a  symptom- 
complex  that  is  observed  with  especial  frequency  in  connection 
with  diseases  of  the  kidneys. 

ALBUMINURIA. 

The  appearance  of  albumin  in  the  urine — albuminuria — must 
always  be  considered  a  morbid  manifestation,  for,  although  it  may 
be  possible  to  obtain  small  amounts  of  albumin  from  large  amounts 
of  urine  from  healthy  persons,  the  urine  of  a  healthy  individual 
appears  always  to  be  free  from  albumin  on  employment  of  the 
usual  clinical  methods  of  examination. 

A  condition  of  physiologic  albuminuria  has  been  described,  in 
which  albuminuria  has  appeared  in  apparently  healthy  persons 
after  walking  long  distances,  bodily  over-exertion  of  other  kinds, 
emotional  disturbances,  cold  baths,  the  ingestion  of  eggs ;  but 
whether  in  these  cases  the  kidneys  were  in  reality  perfectly  healthy 
does  not  appear  to  have  been  demonstrated  with  certainty.  In 
any  event,  too  much  caution  cannot  be  observed  in  admitting  the 
existence  of  physiologic  albuminuria,  for  not  rarely  undoubted 
disease  of  the  kidney  may  make  its  appearance  some  time  later. 

387 


388  GENITO-VRINARY  ORGANS  *■ 

Pathologic  albuminuria  is  by  no  moans  always  associated  with 
disease  of  the  kidneys.  The  urine  may  be  excreted  in  a  healthy 
state  from  the  kidneys  and  become  albuminous  subsequently  from 
admixture  with  pus  or  blood  in  the  urinary  passages.  A  dis- 
tinction can,  therefore,  be  made  between  renal  and  accidental 
albuminuria,  the  latter  being  designated — and,  in  my.  opinion, 
inappropriately — by  French  clinicians  also  false  alhundnuria. 
lienal  albmninuvia  depends,  in  the  first  place,  upon  functional 
disturbance  in  the  epithelial  cells  of  the  blood-vessels  in  the 
jNIalpighian  bodies,  whose  duty  it  is  to  prevent  the  passage  of 
albumin  from  the  blood  into  the  urine.  The  epithelial  cells 
of  the  convoluted  uriniferous  tubules  also  appear  to  exhibit  sim- 
ilar activity.  Even  slight  circulatory  and  nutritive  disturbances 
are  capable  of  inhibiting  the  activity  of  the  structures  named 
without  the  presence  necessarily  of  profound  anatomic  alterations. 
Renal  albuminuria  may  be  the  result  of  primary  disease  of  the 
kidneys,  or  the  kidneys  may  only  be  involved  subsequently  as  a 
result  of  alterations  in  the  blood,  so  that,  accordingly,  a  nephro- 
genous and  a  hematogenous  albuminuria  can  be  considered.  Often 
a  sharp  distinction  is  scarcely  possible. 

While  albuminuria  may  persist  in  some  diseases  for  months 
and  years,  in  others  it  is  but  transitory.  In  the  first  event,  the 
condition  can  be  described  as  persistent,  and  in  the  latter  as  tran- 
sitory albuminuria.  At  times  albuminuria  occurs  daily,  or  at 
definite  other  intervals  Mithin  certain  hours  of  the  day,  and  it  is 
then  designated  cyclic.  Not  rarely  only  the  urine  of  the  day  con- 
tains albumin,  "svliile  that  of  the  night  is  free  from  it,  and  this 
difference  has  been  attributed  to  the  influence  of  bodily  movement. 

For  the  demonstration  of  albuminuria  the  boiling-nitric-acid  test 
and  the  nitric-acid  test  of  Heller  will  suffice  in  most  cases.  Should 
further  confirmation  be  desired,  the  picric-acid  test  of  Galippe,  the 
test  with  yellow  potassium  ferrocyanid  and  acetic  acid  of  Boedecker, 
or  the  test  with  acetic  acid  and  sodium  sulphate  of  Panum  may  be 
employed.  With  all  tests  for  albumin  the  urine  should  be  perfectly 
clear,  and  the  specimen  should,  therefore,  be  filtered.  If  the  urine 
contains  bacteria,  it  will  trenorallv  not  be  clear  even  when  filtered. 
It  should  then  be  shaken  with  heavy  magnesium  ox  id,  and  then 
filtered. 

In  emploj'ing  the  boiUng-nitric-acid  test  the  urine  is  introduced  into  a 
test-tube  and"^  is  boiled.  If  the  urine  is  acid,  and  if  it  remains  clear  on 
boiling,  it  contains  no  albumin.  If.  however,  a  turbidity  ensues,  this  may 
depend  upon  earthy  phosphates,  which  have  been  precipitated  on  heating 
the  urine,  or  upon  coagulated  albumin.  If  on  addition  of  nitric  acid  in  excess 
the  turbidity  disappears,  it  has  been  dependent  upon  earthy  phosphates. 
If,  however,  it  persists,  or  even  increases,  it  is  dependent  upon  albumin,  and 
albuminuria  exists.  Dilute  acetic  acid  (1  per  cent.)  may  be  employed 
instead  of  nitric  acid,  but  great  care  must  be  observed  in  the  addition  of 
acetic  acid,  as  an  excess  may  cause  the  formation  of  acid  albumin,  which  is 
again  soluble  in  the  urine. 


ALBUMINURIA  389 

Heller's  nitric-acid  test  is  an  exceedingly  delicate  and  commendable 
test  for  the  presence  of  albumin.  Several  cubic  centimeters  of  pure  nitric 
acid  are  introduced  into  a  test-tube,  and  upon  this  the  urine  is  carefully- 
permitted  to  flow  along  the  sides  of  the  tube  so  as  to  form  in  a  layer  upon 
the  surface  of  the  acid.  If  albumin  be  present,  a  white,  sharji,  readily 
recognizable  band  will  appear  at  the  line  of  contact.  At  times  a  second 
ring  of  urates  appears  at  a  somewhat  lower  level,  but  this,  in  contradistinc- 
■  tion  from  tbe  ring  of  albumin,  disappears  on  application  of  heat.  Urine 
containing  much  indican  forms  at  times  a  brown  ring,  which  is  readily  and 
clearly  distinguishable  from  the  ring  of  albumin  by  its  color  and  trans- 
parency. 

In  the  performance  of  the  picric-acid  test  of  Galippe  the  solution  of' 
picric  acid  and  citric  acid — so-called  Esbach's  reagent — may  be  advan- 
tageously employed : 

R     Picric  acid,  10.0  (2J  drams) ; 

Citric  acid,  20.0  (5        "      )  ; 

Distilled  water,  1000.0  (32  fluidounces).— M. 
Esbach's  reagent  for  albumin. 

The  presence  of  albumin  in  the  urine  will  be  indicated  by  the  im- 
mediate appearance  of  a  permanent  turbidity  on  addition  of  Esbach's 
reagent  in  excess.  If  the  reagent  be  added  only  drop  by  drop,  each  drop 
as  it  falls  into  the  urine  causes  turbidity,  but  this  disappears  on  agitation 
until  picric  acid  has  been  added  to  the  urine  in  excess.  Care  should, 
further,  be  taken  that  the  urine  does  not  contain  quinin,  antipyrin,  thallin, 
and  potassium-salts,  as  these  likewise  yield  a  precipitate  with  picric  acid. 

Boedecker's  test  for  albumin  loith  yelloio  potassium  ferrocyanid  and  acetic 
acid  is  exceedingly  delicate.  To  several  cubic  centimeters  of  urine  in  a 
test-tube  about  the  same  amount  of  a  concentrated  solution  of  yellow 
potassium  ferrocyanid  is  added,  and  to  the  mixture  concentrated  acetic  acid 
drop  by  drop.  The  presence  of  albumin  is  indicated  by  the  turbidity  that 
appears  with  the  addition  of  each  drop  of  acetic  acid. 

Panum's  test  for  albumin  with  a  saturated  solution  of  sodium  sulphate  and 
acetic  acid  (instead  of  sodium  sulphate,  sodium  chlorid  or  magnesium  sul- 
phate also  may  be  employed)  is  equally  delicate.  Approximately  equal 
parts  of  urine  and  the  solution  of  sodium  sulphate  are  mixed  in  a  test- 
tube,  and  then  several  drops  of  concentrated  acetic  acid  are  added  until 
the  urine  acquires  a  highly  acid  reaction.  If  the  mixture  be  heated, 
turbidity  will  occur  if  the  urine  contains  albumin. 

A  number  of  other  tests  for  albumin  have  been  recommended  (meta- 
phosphoric  acid,  trichloracetic  acid,  etc.),  but  these  are  not  indispensable  to 
the  practitioner. 

The  tests  for  albumin  in  common  clinical  employ  are  applicable 
to  the  two  varieties  of  albumin  particularly  concerned  in  diseases 
of  the  kidneys,  namely,  serum-albumin  and  serum-globulin.  There 
is  scarcely  any  need  on  the  part  of  the  general  practitioner  to 
differentiate  these  two  forms  of  albumin — which,  as  is  well  known, 
form  the  principal  albuminous  bodies  of  the  blood-plasma — and  to 
examine  them  separately.  At  times  other  albuminous  bodies 
appear  in  the  urine,  namely,  .«/6i«7iosftS  (jyropeptones),  and  at  times 
also  nucleo-albumins.  Until  recently  it  was  believed  that  peptones 
also  could  be  eliminated  with  the  urine,  but  peptonuria  does  not 
occur  in  human  beings  if  the  chemic  definition  of  peptones  pro- 
posed by  Kiihne  is  accepted. 


390 


GENITO-URINARY  ORGANS 


iil.lU   >Q.^ 


Albumosuria  can  be  recognized  from  the  fact  that  the  urine  remains 
clear  on  boiling  and  addition  of  nitric  acid,  and  becomes  turbid  only  on 
cooling.  If  the  turbid  urine  be  again  heated,  it  will  again  become  clear. 
A  practical  method  of  examination  for  albumoses  consists  in  performing 
Heller's  test  for  albumin,  and,  if  a  white  ring  of  albumin  forms,  heating 
the  test-tube.  If  the  ring  is  due*  to  albumoses,  it  disappears  on  heating ; 
while  if  due  to  serum-albumin  and  serum-globulin  it  becomes  more  intense. 

There  is  but  one  certain  method  of  determining  the  amount  of 
albumin  in  the  urine,  namely,  boilinir  the  urine,  completely  sepa- 
rating the  albumin  by  careful  addition  of  dilute 
acetic  acid,  and  then  weighing  it,  after  previous 
drying  upon  a  previously  weighed  filter.  Such 
a  procedure  requires  far  too  much  time  for  the 
general  practitioner,  apart  from  the  fact  that  a 
drying  chamber  and  chemic  scales  are  necessary 
for  its  application.  It  is,  therefore,  a  matter  for 
congratulation  that  Esbach  has  described  a  sim- 
ple apparatus  in  the  form  of  his  albuminometer, 
by  means  of  which  the  amount  of  albumin  can 
be  approximately  estimated.  Further,  the  de- 
terminations of  albumin  by  means  of  carefully 
graduated  Esbach  alliuminometers  often  agree 
remarkably  with  the  results  of  weighing. 

Esbach's  albuminojneter  (Fig.  55)  consists  of  a  test- 
tube  of  thick  glass,  which  can  be  closed  by  a  rubber 
stopper.  The  tube  bears  two  principal  marks,  the 
upper  of  which  is  indicated  by  the  letter  R  and  the 
lower  by  the  letter  U.  Below  the  U-line  is  a  scale 
down  to  the  bottom  of  the  tube,  the  lowermost  figure  of 
which  is  2  and  the  uppermost  7.  In  using  the  instru- 
ment the  test-tube  is  filled  with  clear,  filtered  urine  to 
the  line  U  (urine) ;  then  Esbach's  reagent,  consisting, 
as  described,  of  picric  acid  and  citric  acid  (p.  389)  is 
added  up  to  the  line  R  (reagent),  and  with  the  opening 
closed  the  whole  is  inverted  several  times  for  the  pur- 
pose of  thorough  admixture.  The  instrument  is  per- 
mitted to  stand  for  twentv-four  hours  at  room-temper- 
ature (14°  R.— 17.5°  C— 63.5  F.).  At  the  end  of  this 
time  the  level  of  the  column  of  albumin  that  has  been 
deposited  at  the  bottom  of  the  tube  is  read  off.  If,  for 
instance,  the  level  corresponds  with  the  figure  3,  this 
will  indicate  that  3  grams  of  albumin  are  present  in 
1000  c.c.  of  urine,  therefore  0.3  per  cent. 

In  using  the  albuminometer  of  Esbach  the  follow- 
ing facts  should  be  borne  in  mind :  A  knowledge  of  the 
percentage  of  albumin  will  naturally  be  of  value  if  in 
addition  tlie  daily  amount  of  urine  is  known,  and  there- 
from the  total  daily  amount  of  albumin  is  estimated. 
The  temperature  of  the  room  in  which  the  albuminometer  is  kept  should 
not  be  below  14°  R.  (17.5°  C. — 63.5°F.),  as  otherwise  the  albumin  will  not 
be  precipitated.  Xow  and  then,  although  rarely,  urine  is  encountered  in 
which,  in  spite  of  the  observance  of  all  precautions,  no  precipitate  of  albu- 
min takes  place,  but  a  cloud  of  albumin  floats  in  the  upper  layers  of  the 


Fig.  55. — Esbach's 
albuminometer;  nat- 
ural size. 


ALB  UMINUBIA  391 

urine.  Should  the  urine  contain  more  than  0.7  per  cent,  of  albumin,  it 
should  be  diluted  with  an  equal  amount  of  water  before  it  is  introduced 
into  the  albuminometer.  The  patients  shall  not  have  used  quinin,  anti- 
pyrin,  thallin,  and  potassium-salts,  as  picric  acid,  as  has  already  been  men- 
tioned, forms  precipitates  with  these  substances. 

The  amount  of  albumin  eliminated  with  the  urine  is  susceptible 
of  great  variation  in  accordance  with  the  causes  of  the  albumin- 
uria. At  times  only  traces  of  albumin  will  be  present,  with  a 
scarcely  appreciable  turbidity  of  the  previously  clear  urine,  while 
in  other  instances  the  boiled  urine  may  become  a  solid  coagulum, 
which  will  not  flow  from  the  inverted  tube. 

On  careful  inquiry  into  the  clinical  causes  of  alhuminuriay 
hematogenous  albuminuria  will  be  found,  first,  as  a  result  of  circu- 
latory disorders.  Both  anemia  and  venous  hyperemia  of  the  kid- 
neys are  frequently  attended  with  albuminuria.  The  nervous 
albuminuria  that  appears  in  the  sequence  of  epileptic  attacks, 
cerebral  hemorrhage,  tetanus,  hysteria,  progressive  paralysis  of 
the  insane,  etc.,  is  often  probably  also  due  to  disturbances  in  the 
renal  circulation.  Not  rarely  albuminuria  is  associated  with  anemic 
and  cachectic  states,  although  under  such  circumstances  there  is  fre- 
quently a  connection  with  hematogenous  albuminuria,  because  in 
the  course  of  the  conditions  named  fatty  degeneration  readily 
develops,  particularly  in  the  epithelial  cells  of  the  convoluted 
uriniferous  tubules.  Nephrogenous  cdbuminuria  occurs  particularly 
in  association  with  diffuse  inflammatory  conditions  of  the  kidneys, 
but  also  with  all  other  possible  diseases  of  the  kidneys.  Febrile 
or  infectious  and  toxic  cdbuminuria  should  further  be  mentioned  as 
especial  varieties  of  nephrogenous  albuminuria.  Febrile  infectious 
diseases  are  frequently  attended  with  albuminuria.  The  injury 
to  the  renal  epithelium  under  such  conditions  is  dependent  proba- 
bly less  upon  the  elevation  of  bodily  temperature  than  upon  the 
infection,  as  afebrile  infectious  diseases  may,  likewise,  give  rise  to 
albuminuria.  Probably  bacterial  poisons  (toxins)  are  the  sub- 
stances that  cause  irritation  of  the  kidneys  in  the  process  of  elimi- 
nation with  the  urine.  Toxic  albuminuria  may  be  induced  by 
many  substances,  whether  introduced  through  the  mouth,  the 
rectum,  or  the  skin.  Among  these  may  be  mentioned  mineral 
acids,  carbolic  acid,  mercuric  chlorid,  phosphorus,  arsenic,  lead, 
cantharides,  balsamics,  and  irritating  applications  to  the  skin  of 
all  kinds.  Albuminuria  occurs  also  at  times  after  burns  of  the 
skin  and  chronic  cutaneous  eruptions,  in  all  probability  induced 
by  the  absorption  of  toxic  substances  from  the  skin. 

The  danger  from  albuminuria  does  not  reside  in  the  loss  of 
albumin,  for  an  albuminuria  with  the  loss  of  more  than  20.0 
grams  of  albumin  daily  is  rare,  and  could  easily  be  compensated 
for  by  the  ingestion  of  several  eggs  or  of  meat.  Therefore  the 
prognosis    of    cdbuminuria    depends    solely    upon    the    causa- 


392  GEXITO-URINARY  ORG  ASS 

tive  factors.     When    these   are    incurable    so   also    is  the   allju- 
miuuria. 

In  the  treatment  of  albuminuria  the  nourishment  and  the 
mode  of  life  play  the  most  important  part.  No  medicine  is  known 
capable  of  curing  albuminuria,  and  tannic  acid,  fuchsin,  brom- 
benzol,  strontium  lactate,  and  strontium  bromid  have  been  incor- 
rectly recommended  as  such.  Patients  with  alljumiuuria  should 
avoid  -aW  food  and  drinh  capable  of  irritating  the  kidneys,  particu- 
larly strong  coffee  and  tea,  alcoholics,  sharp  spices  and  acids,  and 
asparagus.  A  milk-diet  is  particularly  to  be  recommended  :  from 
1  to  2  quarts  of  thoroughly  boiled  milk  being  taken  in  small 
amounts  tliroughout  the  day.  Meat  should  be  taken  only  in  mod- 
erate amount,  and  white  meat  (lamb,  veal,  poultry)  particularly  is 
to  be  preferred.  Vegetables  and  light  pastry  may  be  recom- 
mended. Thirst  should  be  relieved  by  acid  or  alkaline  waters 
(Vichy,  Bilin,  Giesshiibel,  Ems,  Fachingen,  etc.).  The  patient 
should  wear  flannel  next  to  the  skin,  and  take  twice  weeklv  a  bath 
at  a  temperature  of  28°  R.  (35°  C— 95°  F.).  All  exposure  to  cold 
should  be  carefully  avoided.  In  the  winter  the  well-to-do  should 
be  advised  to  sojourn  in  an  equable,  warm  southern  climate.  I 
have  observed  excellent  results  in  a  number  of  instances  from  a 
winter  spent  in  Helouan,  near  Cairo.  Bodily  over-exertion  should 
not  be  permitted  under  any  circumstances,  as  it  may  cause  a  re- 
currence of  a  cured  albuminuria. 


HEMATURIA. 

The  presence  of  blood  in  the  urine  is  designated  hematuria 
when  the  urine  contains  sufficient  hemoglobin  to  give  rise  to  a  dis- 
tinctly bloody  hue.  Two  varieties  of  hematuria  must,  however, 
be  distinguished,  accordingly  as  red  blood-corpuscles  or,  after 
previous  solution  of  red  blood-corpuscles,  only  free  iiemoglobin  is 
present  in  the  urine.  The  latter  condition  is  designated  hemo- 
globinuria, as  opposed  to  the  more  common  occurrence  of  hema- 
turia. 

Hematuria  is  readily  recognized  from  the  distinctive  color  of 
the  urine.  In  accordance  with  the  number  of  red  blood-corpus- 
cles present  in  the  urine,  and  the  transformation  of  their  con- 
tained hemoglobin  into  methemoglobin,  the  urine  exhibits  a  light- 
rose  color,  suggestive  of  the  appearance  of  meat-infusion,  or  pre- 
senting a  blood-red,  brownish,  or  even  blackish  appearance. 
Should  any  doubt  exist  as  to  the  nature  of  the  condition,  the  urin- 
ary sediment  should  be  examined  for  red  blood-corpuscles,  or 
Heller's  blood-test  should  be  ]ierformed.  The  red  blood-corpus- 
cles in  the  urinary  sediment,  which  often  discloses  the  presence  of 
blood  by  its  brownish-color,  are  at  times  unchanged  in  form, 
alt!iough  at  other  times  (particularly  in  concentrated  urine)  thev 


HEMATURIA  393 

exhibit  thorn-apple  processes,  or  they  appear  swollen  and  bi- 
convex, or  lentil-shaped  and  even  spherical.  At  times  unusually 
small  spherical  red  blood-corpuscles  are  encountered — so-called 
microcytes.  Frequently  red  blood-corpuscles  have  yielded  up 
their  hemoglobin  and  appear  as  colorless  discs  of  double  contour 
— so-called"  blood-shadows.  At  times,  particularly  in  the  hot 
summer  months,  ameboid  movement  and  constrictions  can  on 
careful  observation  be  detected  in  isolated  red  blood-corpuscles. 
Should  tube-casts  appear  in  the  urine  in  association  with  renal 
hematuria,  they  may  be  covered  with  red  blood-corpuscles  or  be 
entirely  constituted  of  them  (blood-clasts).,  Tube-casts  and  epi- 
thelial cells  from  the  uriniferous  tubules  also  not  rarely  present 
a  blood-stained  or  a  brownish  discoloration  with  hemoglobin. 
Rarely,  hematoidin-crystals  are  present  in  urinary  sediment.  It  is 
noteworthy  that  the  red  blood-corpuscles  in  the  urine  are  almost 
never  arranged  upon  one  another  in  columns  or  in  rouleaux,  but 
are  separated  from  one  another,  or  lie  in  contact  only  at  their 
borders. 

Hellers  blood-test  is  performed  as  follows :  Several  cubic  centimeters  of 
urine  are  introduced  into  a  test-tube,  and  potassium  hydroxid  is  added  in 
excess  until  the  urine  acquires  an  alkaline  reaction.  If  the  mixture  be 
heated,  the  earthy  phosphates  are  precipitated  on  boiling  in  the  form  of 
coarse  flocculi,  which  after  a  time  are  deposited  upon  the  bottom  of  the 
tube.  In  urine  free  from  blood  this  precipitate  appears  gray,  while  in  urine 
containing  blood  it  acquires  a  reddish,  brownish,  or  brownish-black'appear- 
ance.  The  test  is  so  delicate  that  spectroscopic  examination  of  the  urine  and 
Teichmann's  blood-test  are  unnecessary. 

Bloody  urine  is  necessarily  albuminous,  as  the  hemoglobin  con- 
sists of  blood  coloring-matter  and  proteid.  So  long  as  the  condi- 
tion is  one  of  pure  hematuria  the  urine  contains  only  so  much 
albumin  as  corresponds  with  the  amount  of  blood  present.  The 
amount  of  albumin  is  increased  when,  in  addition  to  hematuria, 
albuminuria  also  exists.  The  reaction  of  the  urine  depends  upon 
the  nature  of  the  primary  disease.  In  any  event  the  presence 
of  even  quite  a  considerable  amount  of  blood  in  the  urine  is  never 
capable  of  rendering  alkaline  the  naturally  acid  reaction  of  the 
urine. 

The  causes  of  hematuria  reside  in  alterations  either  in  the  kid- 
neys or  in  the  urinary  passages,  and  the  character  of  the  hematuria 
varies  accordingly.  With  renal  hematuria  the  blood  is  intimately 
admixed  with  urine,  and  retains  the  same  color  and  character  at 
the  beginning  and  at  the  end  of  the  act  of  micturition.  Hemor- 
rhages from  the  pelvis  of  the  kidney  and  the  ureters  disclose  their 
origin  frequently  from  the  appearance  in  the  urine  of  cylindric 
blood-clots,  which  represent  casts  •  of  the  ureter.  With  hemor- 
rhages from  the  bladder  the  urine  first  voided  is  frequently  less 
bloody  than  that  evacuated  last,  because  the  blood,  by  reason  of  its 


394  (iEXITO-UPiIXAIiY  ORGANS 

weiglit,  has  collected  in  particular  abundance  in  the  fundus  of  the 
bhuldcr.  Hemorrhages  from  the  urethra,  finally,  are  very  slight, 
and  often  at  the  beginning  of  the  act  of  micturition  a  few  drops  of 
blood  make  their  apj)earance.  With  hemorrhages  from  the  poste- 
rior portion  of  the  urethra  a  few  drops  of  blood  are  expelled  only 
toward  the  close  of  the  act  of  micturition,  and  often  with  painful 
tenesnuis. 

Renal  hemorrhage  occurs  in  connection  with  numerous  diseases 
of  the  kidneys,  as,  for  instance,  acute  nephritis,  embolism  of  the 
renal  artery,  carcinoma  of  the  kidney,  renal  tuberculosis,  echino- 
coccus  of  the  kidney,  and  injury  of  the  kidney.  At  times  renal 
hematuria  is  dependent  upon  alterations  in  the  blood,  among  the 
causes  of  which  leukemia,  pseudoleukemia,  pernicious  aneuiia, 
scorbutus,  purpura,  and  hemophilia  may  be  mentioned.  At  times 
hematuria  occurs  in  the  course  of  infectious  diseases  if  these  assume 
the  so-called  hemorrhagic  character,  and  give  rise  to  hemorrhages 
of  all  kinds.  Toxic  hemorrhage  from  tlie  kidney,  such  as  may  be 
observed  folloAving  the  ingestion  of  cantharides,  quinin,  salicylic 
acid,  potassium-salts,  mineral  acids,  carbolic  acid,  etc.,  is  worthy 
of  especial  mention.  Hemorrhages  from  the  pehis  of  the  kidney  and 
the  ureter  are  induced  most  commonly  by  renal  calculi,  less  com- 
monly by  parasites,  carcinoma,  tuberculosis,  or  by  rupture  of  an 
aneurysm  of  the  renal  artery. 

Hemorrhages  from  the  bladder  occur  in  connection  with  cystitis, 
vesical  calculi,  carcinoma,  tuberculosis,  parasites,  and  in  the 
sequence  of  injuries  (exterual  and  internal,  with  the  catheter).  At 
times  the  veins  surrounding  the  neck  of  the  bladder  undergo  dila- 
tation, forming  so-called  vesical  hemorrhoids,  which  by  rupture 
may  give  rise  to  profuse  hemorrhage  from  the  bladder. 

Hemorrhage  from  the  urethra  occurs  in  comiection  with  severe 
gonorrhea  (so-called  Russian  gonorrhea),  with  impaction  of  urinary 
calculi  and  injuries  with  the  catheter. 

Hematuria  is  but  rarely  attended  with  such  profuse  loss  of 
blood  that  life  is  endangered  by  hemorrhage.  Should  life  be 
threatened,  the  danger  will  depend  rather  upon  the  causes  of  the 
hematuria.  The  latter  influence  is  responsible  also  for  the  fact 
that  hematuria  is  of  variable  duration,  and  either  terminates  with 
a  single  attack  or  is  frequently  repeated. 

The  treatment  of  hem(duria  must  be  directed  to  the  causative 
conditions.  Under  all  circumstances  bodily  rest  is  indicated.  Not 
much  can  be  hoped  for  from  hemostcdies. 

Hemoglobinuria  indicates  the  occurrence  of  dissolved  blood 
coloring-matter  in  the  urine.  Hemoglobinuria  is  invariably  pre- 
ceded by  hemoglol)inemia  ;  that  is,  red  blood-corpuscles  have  first 
been  dissolved  in  the  blood  and  have  given  up  their  coloring-matter 
to  the  blood-plasma.  Naturally  the  hemoglobinemia  must  have 
attained  a  certain  decree  of  intensity  before  hemoo;lol)inuria  occurs, 


HEMATURIA  395 

for  the  spleen,  the  liver,  and  the  lymphatic  glands  are  capable  of 
taking  up  the  dissolved  hemoglobin  from  the  blood-plasma  and 
utilizing  it  if  the  hemoglobinemia  be  but  slight.  Hemoglobinemia 
and  liemoglobinuria  are  most  commonly  caused  by  the  action  of 
toxic  substances  upon  the  blood,  either  of  chemic  or  of  bacterial 
origin  (toxins).  Among  chemic  poisons  potassium  chlorate  particu- 
larly is  well  knoAvn  as  a  solvent  for  blood-corpuscles  and  as  a  cause 
for  hemoglobinuria.  A  similar  influence  is  exerted  by  quinin, 
mineral  acids,  carbolic  acid,  nitrobenzol,  aniline-oil,  copper  sul- 
phate, hydrogen  arsenid,  etc.  Hemoglobinuria  can  be  induced  in 
human  beings  by  transfusion  of  blood  from  animals.  Occasionally 
hemoglobinuria  has  been  observed  after  the  ingestion  of  fimgi,  par- 
ticularly mussels.  Among  infectious  diseases,  in  the  sequence  of 
which  hemoglobinuria  has  been  observed,  typhoid  fever,  pharyn- 
geal diphtheria,  malaria,  acute  miliary  tuberculosis,  small-pox, 
septicemia,  and  syphilis  may  be  named.  The  hemoglobinuria 
attending  afebrile  cyanosis  of  the  newborn,  and  following  burns 
of  the  skin,  should  further  be  mentioned.  At  times  hemoglobin- 
uria occurs  in  association  with  diseases  of  the  blood,  as,  for  instance, 
purpura  and  scorbutus.  It  has  been  observed  also  in  the  sequence 
of  sunstroke  and  fat-embolism.  Paroxysmal  hemoglobinuria  will  be 
considered  among  the  diseases  of  the  blood. 

In  cases  of  hemoglobinuria  the  urine  presents  a  bloody  appear- 
ance, at  times  like  that  of  fresh  blood,  but  often  reddish-brown, 
as  the  urine  frequently  contains  an  abundance  of  methemoglobin. 
The  urine  in  a  thin  layer  is  transparent ;  it  yields  Heller's  test  for 
blood,  although  in  the  often  brownish-discolored  urinary  sediment 
either  no  red  blood-corpuscles  at  all  are  found  or  but  a  small 
number  of  usually  discolored  shadows,  so  that  there  will  be  no 
doubt  that  the  condition  is  one  of  hemoglobinuria.  Often  the 
blood  coloring-matter  forms  flocculent  and  filamentous  brownish 
and  greenish  irregularly  shaped  masses,  and  tube-casts  of  com- 
pressed blood  coloring-matter  also  appear.  Such  epithelial  cells 
from  the  uriniferous  tubules  as  may  be  present  are  frequently 
stained  brownish  or  greenish  by  hemoglobin.  At  times  crystals 
of  hematoidin  also  are  present.  On  boiling  the  urine  a  finely  floc- 
culent precipitate  of  albumin  does  not  occur,  but  there  results  a 
large,  coherent  coagulum  of  albumin,  stained  brownish  by  hemo- 
globin. Spectroscopic  examination  of  the  urine  reveals,  in  addition 
to  the  two  bands  of  oxyhemoglobin  between  the  Fraunhofer  lines 
D  and  E,  the  bands  of  methemoglobin,  of  which  especially  that 
between  the  lines  C  and  D  is  usually  distinct.  Only  rarely  are 
the  bands  of  methemoglobin  alone  visible. 

The  prognosis  of  hemoglobinuria  depends  upon  the  causa- 
tive condition,  and  the  same  statement  is  applicable  also  to  the 
treatment. 


396  GENITO-URINARY  ORGANS 

Hnnatinuria  has  rarely  been  observed,  as,  for  instance,  after  pharyngeal 
diphtheria.  Within  recent  years  attention  has  been  directed  to  hematnpor- 
phi/riiiui-ia,  which  has  been  observed  particularly  in  connection  with  the 
toxic  effects  of  sulphonal  and  trional,  and  with  typhoid  fever  and  mental 
disease.    The  prognosis  is  unfavorable. 

UREMIA. 

Ktiology. — Uremia  is  a  symptom-complex  that  is  not  rarely 
observed  in  the  sequence  of  diseases  of  the  kidneys.  In  order  to 
avoid  repetition,  it  will  not  be  without  utility  to  precede  a  con- 
sideration of  the  individual  diseases  of  the  kidneys  by  a  descrip- 
tion of  uremia.  The  conditions  for  the  development  of  uremia 
are  always  provided  when  the  elimination  of  certain  toxic  sub- 
stances with  the  urine  is  interfered  with.  This  occurs  most  com- 
monly when  the  amount  of  urine  is  diminished  in  abnormal  degree, 
although  uremia  may  occur  also  when  the  amount  of  urine  is 
al)undant  if  the  secretion  contains  a  deficiency  of  toxic  substances 
which  are  retained  within  the  body.  Uremia  is  accordingly  the 
result  of  an  intoxication,  or,  as  it  is  now  customary  to  designate 
it,  an  auto-intoxication,  as  the  condition  is  dependent  upon  toxic 
substances  generated  by  the  body  itself. 

The  nature  of  the  toxic  substances  is  not  known.  The  so-called  urinous 
substances  have  been  thought  of  (urea  and  its  decomposition-product — 
ammonium  carbonate — kreatinin,  potassium-salts,  sodium  chlorid),  but  of 
late  there  has  been  a  tendency  to  adopt  the  view  that  the  responsible  factors 
may  consist  in  putrefactive  alkaloids — ptomains. 

Although  diseases  of  the  kidneys  constitute  the  most  common 
cause  of  uremia,  they  are,  however,  not  the  sole  cause.  Diseases 
of  the  urinary  passages,  also,  may  be  attended  M'ith  uremia  if 
they  interfere  with  the  elimination  of  urine.  Among  diseases  of 
the  kidneys  particularly  acute  and  chronic  interstitial  nephritis  give 
rise  to  uremia  most  commonly.  It  is  noteworthy  that  at  times 
severe  irritation  of  one  kidney  may  through  reflex  influences  cause 
suppression  of  the  function  of  the  other  kidney,  and  thereby  give 
rise  to  uremia.  A  similar  condition  has  been  observed  in  con- 
nection with  nephrectomy  and  the  presence  of  a  calculus  in  a  ureter. 
In  some  cases  uremia  results  from  obstruction  by  a  calculus,  not 
of  one  ureter  merely,  but  of  each.  Occlusion  of  both  ureters  may 
be  caused  by  new-growths  of  the  bladder,  the  rectum,  and  the 
uterus,  as  well  as  by  tuberculosis  of  both  ureters.  Among  dis- 
eases of  the  bladder  paralysis  of  this  viscus,  and  in  connection 
therewith  urinary  stasis,  may  induce  uremia.  Even  when  the 
bladder  becomes  over-distended  in  consequence  of  .stupor  there 
will  be  danger  of  uremia.  This  may  develop  also  if  the  orifice 
of  the  bladder  is  obstructed  by  calculi,  new-growths,  or  pressure 
from  M'ithout.  Finally,  strictures,  laceration,  and  compression  of 
the  urethra,  and  phimosis  may  be  causes  of  uremia.     Uremia  may 


UREMIA  397 

occur  at  any  j^eriod  of  life.     In  children  it  develops  most  com- 
monly as  a  result  of  acute  nephritis  following  scarlet  fever. 

Symptoms  and  Diagnosis. — The  symptoms  of  uremia  con- 
sist particularly  in  nervous  and  inflammatory  manifestations,  the 
former  being  the  result  of  irritation  of  the  brain  by  the  retained 
toxic  substances,  and  the  latter  being  due  to  the  fact  that  the  resist- 
ance of  the  tissues  of  the  organism  is  diminished  when  the  latter  is 
saturated  with  excrementitious  products.  A  most  common  symp- 
tom is  headache — cephalalgia — which  at  times  is  diffused  over  the 
entire  head,  at  other  times  is  located  in  the  forehead,  the  vertex, 
or  the  occiput,  and  at  still  other  times  exhibits  a  unilateral  dis- 
tribution— uremic  hemicrania.  Obstinate  neuralgia,  particularly 
supra-orbital  and  occipital,  is  not  rarely  dependent  upon  uremia. 
Some  patients  complain  of  migratory  muscular  and  articular  pains. 
Vertigo,  a  sense  of  weight  and  pressure  in  the  head,  also  are  symp- 
toms of  uremia.  Frequently  disorders  of  the  special  senses  are 
present ;  the  pupils  not  rarely  are  unusually  small — uremie  myosis 
— and  they  react  but  sluggishly  to  light.  At  times  sudden  blind- 
ness occurs — uremic  amaurosis — which  may  disappear  in  the 
course  of  a  few  hours  or  days.  Many  patients  complain  from 
time  to  time  of  deafness  and  tinnitus  aurium.  An  important 
symptom  of  uremia  is  frequent  and  persistent  vomiting — uremic 
hyperemesis — probably  in  consequence  of  irritation  of  the  vagus. 
Consciousness  is  often  obtunded.  The  patients  lie  for  days,  and 
even  for  weeks,  in  a  state  of  stupor,  and  are  often  delirious.  At 
times  they  become  violent  and  maniacal,  and  enter  into  a  pro- 
nounced psychopathic  condition.  When  consciousness  is  lost  the 
respiration  often  acquires  a  Cheyne-Stokes  character.  Uremic 
convulsions  occur  frequently.  These  are  usually  clonic,  and  but 
rarely  tonic.  They  may  involve  circumscribed  groups  of  nerves 
and  muscles,  and  consist  in  briefly  transient  muscular  twitching ; 
or  there  may  be  general  clonic  convulsions,  with  loss  of  conscious- 
ness, completely  resembling  an  epileptic  attack — uremic  eclampsia. 
The  duration  and  the  number  of  the  convulsions  are  susceptible 
of  great  variation.  At  times  the  attacks  succeed  one  another  at 
short  intervals  for  days,  the  patient  not  returning  to  consciousness 
after  the  termination  of  the  individual  attack.  At  times  they 
present  the  distinct  character  of  cortical  convulsions,  beginning 
in  a  given  extremity,  and  then,  in  accordance  with  the  anatomic 
situation  of  the  individual  motor  cortical  centers,  extending  to 
the  remaining  extremity  of  the  same  side,  and  then  to  those  of 
the  opposite  side. 

Rarely  uremic  paralysis  occurs,  in  the  form  of  monoplegia  and  hemi- 
plegia. Anatomic  alterations  may  not  be  discernible  in  the  central  nervous 
system.  In  isolated  cases  I  have  observed  circumscribed  edema  of  the  pia 
in  the  neighborhood  of  the  central  convolutions  of  the  cerebral  hemisphere 
on  the  side  opposite  to  that  of  the  hemiplegia.    At  times  transitory  paralysis 


398  GEyiTO-URIXARY  ORGANS 

l)ersists  after  uremic  convulsions.  I  have,  however,  also  observed  perma- 
nent hemiplegia  in  consequence  of  cerebral  hemorrhage  during  the  con- 
vulsive seizure.     Sometimes  violent  uremic  tremor  is  noticeable. 

Some  patients  complain  of  paresthesia  (crawling,  prickling, 
a  sense  of  cold).  Particularly  disagreeable  is  the  often  obstinate 
itching  of  the  skin — cutaneous  pruritus.  Among  the  nervous  mani- 
festations of  uremia  are  attacks  of  intense  dyspnea — uremic  astlima. 
Attacks  of  uremic  cardiac  asthma  have  also  been  observed.  Among 
the  injiainmatory  ^/jani'/e.s-to^ion.S' of  nremia,  diseases  of  the  skin  may 
be  mentioned,  and  which  have  been  dignified  with  the  euphonious 
designation  of  uremicles.  Among  these  belongs  particularly  chronic 
eczema,  although  I  have  also  observed  herpes  zoster  in  the  course 
of  uremia.  At  times  obstinate  diarrhea  occurs.  This  may  be  char- 
acterized by  the  putrid  odor  of  the  stools,  which  contain  at  times 
necrotic  shreds  of  the  intestinal  mucous  membrane.  Some  patients 
suffer  from  obstinate  hoarseness,  the  cause  for  which  may  be  found 
on  laryngoscopic  examination  to  be  chronic  edema  of  the  laryngeal 
mucous  membrane. 

In  isolated  rare  instances  I  have  observed  yellowish  necrotic  deposits 
upon  the  laryngeal  and  pharyngeal  mucous  membrane,  from  which  super- 
ficial uremic  ulcers  developed. 

A  most  serious  manifestation  is  the  occurrence  of  acute  edema 
of  the  glottis,  which  may  cause  death  by  suffocation  w'ithin  a 
short  time.  At  times  symptoms  of  pneumonia  appear  suddenly. 
The  serous  membranes  are  particularly  predisposed  to  inflamma- 
tion, so  that  uremic  pleurisy  or  pericarditis,  less  commonly,  peri- 
tonitis or  meningitis,  is  encountered.  The  saturation  of  the  body 
W'ith  toxic,  excrementitious  substances  in  uremia  is  at  times  indi- 
cated by  symptoms  of  blood-dissolution,  which  can  scarcely  occur 
otherwise  than  in  consequence  of  impairment  of  the  nutrition  of 
the  walls  of  the  blood-vessels,  so  that  these  readily  rujiture  or 
become  unduly  permeable  for  red  blood-corpuscles.  Often  fre- 
quent or  profuse  bleeding  from  the  nose — uremic  epistaxis — occurs; 
or  there  may  be  vomiting  of  blood — uremic  hematemesis.  Also 
cutaneous  hemorrhage — uremic  purpura — and  bleeding  from  the  gums 
have  been  observed.  Uremic  patients  generally  present  a  pallid 
complexion.  The  facial  expression  appears  distorted,  and  the  eyes 
often  stare  vacantly  into  distance.  In  many  instances  the  expired 
air  possesses  a  urinous  odor,  obviously  resulting  from  decomposed 
urea,  and  thus  from  ammonium  carbonate.  In  isolated  instances 
of  uremia  following  scarlet  fever  and  cholera  a  Avhitish  deposit 
has  been  observed  to  remain  upon  the  skin  after  previous  sweat- 
ing, and  which  upon  chemic  examination  proved  to  be  urea — 
so-called  uridrosis.  The  bodily  temperature  is  subnormal  in  the 
majority  of  cases,  although  elevation  of  temperature  may  occur 
when  inflammatory  processes  arise,  at  times  with  uremic  convul- 
sions, and  at  times  also  without  demonstrable  cause.    Great  atten- 


UREMIA  399 

tion  should  be  given  to  the  state  of  the  pulse,  for  some  cases  of 
uremia  depend  upcm  attacks  of  cardiac  failure,  and  this  can  be 
most  certainly  recognized  from  the  smallness  of  the  pulse  and  its 
deficiency  in  tension.  At  times  the  outbreak  of  an  attack  of  uremia 
is  preceded  by  unusual  slowing  of  the  pulse.  The  urine  is  gener- 
ally diminished  in  amount.  If  its  elimination  can  be  augmented, 
the  large  number  of  tube-casts  in  the  urinary  sediment  is  often 
striking,  and  which  obviously  had  previously  obstructed  the 
uriniferous  tubules. 

The  course  of  uremia  may  be  acute,  subacute,  or  chronic.  It 
may  happen  that  apparently  healthy  persons  are  suddenly  seized 
with  uremic  convulsions  and  death  occurs.  Perhaps  examination 
of  the  urine  after  death  will  for  the  first  disclose  the  fact  that  the 
patient  has  suffered  from  an  unrecognized  contracted  kidney.  The 
subacute  cases  may  extend  over  eight  weeks,  and  even  more,  while 
the  chronic  cases  persist  for  months  and  years.  In  the  latter  event 
it  is  the  rule  for  such  marked  improvement  to  occur  at  times 
that  the  patient  believes  himself  cured.  Death  may  take  place  in 
a  uremic  convulsion  from  cerebral  or  neural  paralysis,  or  it  may 
be  due  to  edema  of  the  glottis  or  of  the  lungs,  or  an  attack  of  pneu- 
monia, of  pleurisy,  or  of  pericarditis  may  terminate  life.  At  times 
exhaustion  becomes  excessive. 

The  diagnosis  of  uremia  is  easy  if  adequate  attention  be  di- 
rected to  the  eliminative  relations  of  the  urine  and  the  presence 
therein  of  albumin.  Otherwise  confusion  with  diseases  of  the  brain, 
epilepsy,  meningitis,  mental  disease,  cutaneous  disease,  disease  of 
the  stomach,  and  even  other  diseases,  is  scarcely  to  be  avoided. 
Katurally  a  diagnosis  of  uremia  will  never  be  sufficient,  but  in 
every  instance  an  effort  must  be  made  to  determine  the  nature  and 
the  causes  of  the  condition,  because  the  treatment  will  be  indi- 
cated accordingly. 

Anatomic  Alterations. — No  specific  anatomic  conditions 
are  as  yet  known  to  be  associated  with  uremia.  At  times,  but 
by  no  means  with  particular  frequency,  edema  and  anemia  of  the 
brain  are  observed.  The  inconstancy  of  these  conditions  is  un- 
equivocal testimony  against  the  view  that  tlie  nervous  manifesta- 
tions of  uremia  are  dependent  upon  edema  and  anemia  of  the 
brain.  At  times  peculiar  necrotic  alterations  and  destructive  pro- 
cesses take  place  upon  the  intestinal  mucous  membrane — uremic  in- 
testinal ulcers.  These  have  been  attributed  to  irritation  of  the 
mucous  membrane  by  ammonium  carbonate  resulting  from  the  de- 
composition of  urea  excreted  from  the  blood-vessels  and  deposited 
upon  tlie  mucous  membrane. 

Prognosis. — The  prognosis  of  uremia  is  always  serious, 
although  it  depends  largely  upon  the  fact  w^hether  the  causes  are 
susceptible  of  removal  or  not.  Accordingly,  it  is,  for  instance, 
more  favorable  in  cases  of  acute  nephritis,  or  of  impaction  of  a 


400  GEXITO-URIXABY  ORGANS 

calculus,  than  in  those  of  contracted  kidney,  because  under  the 
latter  condition  the  disease  is  incurable. 

Treatment. — The  treatment  of  uremia  must  always  be  an 
individualizing  and  causal  one.  Phimosis  or  stricture  of  the 
urethra  should  be  at  once  relieved.  In  the  presence  of  stupor 
or  of  paralysis  of  the  bladder  the  urine  should  be  systematically 
evacuated  with  a  carefully  sterilized  catheter.  In  order  to  in- 
crease the  secretion  of  urine  and  hasten  the  elimination  from  the 
body  of  possible  toxic  products  of  metabolism  an  abundance  of 
inUk  should  be  reconnuended.  When  stupor  is  present  intestinal 
infusions  of  lukewarm  milk  or  of  physiologic  salt-solution  (0.75 
per  cent.)  should  be  made  tlirice  daily.  If  the  patient  does  not 
retain  the  infusion,  even  though  not  more  than  300  c.c.  of  fluid 
have  been  used,  subcutaneous  infusion  of  salt-solution  should  be 
practised.  If  the  secretion  of  urine  does  not  improve,  diuretics, 
diaphoretics,  or  drastics  may  be  employed  to  cause  increased  elim- 
ination of  water.  Should  these  measures  also  fail,  resort  should 
be  had  to  venesection.  If  the  patient  exhales  a  markedly  urinous 
odor,  lemonade  and  benzoic  acid  ivith  camphor  should  be  given  in 
order  to  neutralize  the  ammonium  carbonate  : 

R  Benzoic  acid,  0.3    (4J  grains); 

Camphor,  0.05  (f  grain  ); 

Sugar,  0.5    {7J  grains). — M. 

Make  10  such  powders. 
Dose :  1  powder  everv  two  hours. 

Feebleness  of  pulse,  faintness  of  heart-sounds,  and  other  signs 
of  cardiac  weakness  require  the  administration  of  large  doses  of 
digitalis : 

R  Powdered  digitalis-leaves,  0.1    (li  grains); 

Diuretin,  1.0    (15       "     ); 

Sugar,  0.5    [1\      "    ).— M. 

Make  10  such  powders. 
Dose :  1  powder  every  three  hours. 

The  last  two  indications  can  also  be  met  by  the  following  pre- 
scription : 

R   Powdered  digitalis-leaves,  0.1    (1^  grains) ; 

Benzoic  acid,  0.3    (4}       "     ) ; 

Camphor,  0.05  (J  grain  ) ; 

Sugar,  0.5    (7^  grains).— M. 
Make  10  such  powders. 
Dose :  1  powder  every  three  hours. 

At  times  individual  prominent  symptoms  will  require  symptom- 
atic treatment.  Attempts  have  been  made  to  control  persistent 
eclamptic  convulsions  by  continuous  inhalation  of  chloroform.  For 
uremic  neuralgia  phenacetin  or  anfipi/rin  may  be  advised  (1.0 — 
15  grains — thrice  daily).  INIarkcd  itchiuir  of  the  skin  niav  l)e  re- 
lieved by  tepid  baths  (28°  R.— 35°  C— 95°  F.)and  inunctions  of 


HYPOSTATIC  KIDNEY  401 

the  skin  with  a  carholated  ointment  (carbolic  acid,  2.0 — 30  grains  ; 
wool-fat  and  lard,  each,  25.0 — |  ounce),  etc. 

HYPOSTATIC  KIDNEY  (VENOUS  HYPEREMIA  OF 
THE  KIDNEY). 

etiology. — Hypostatic  kidney  develops  when  the  escape  of 
venous  blood  from  the  kidney  is  interfered  with.  The  condition 
develops  most  commonly  in  the  sequence  of  general  venous  stasis 
in  connection  with  chronic  diseases  of  the  heart  and  the  respiratory- 
organs.  Enfeeblement  of  the  right  ventricle  is  invariably  the 
source  of  the  stasis  in  this  connection.  Less  commonly  hypostasis 
of  the  kidney  develops  in  association  with  diseases  of  the  abdom- 
inal cavity,  as,  for  instance,  abdominal  tumors  that  exert  pressure 
upon  the  inferior  vena  cava  above  the  point  of  entrance  of  the 
renal  veins.  Finally,  hypostatic  kidney  may  develop  as  a  result 
of  local  obstruction  or  occlusion  of  the  renal  veins,  as,  for  instance, 
by  thrombosis.  Instances  of  the  latter  variety,  which  are  as  yet 
of  little  significance  clinically,  are  distinguished  from  those  of  the 
two  varieties  first  named  by  the  fact  that  the  arterial  supply  to  the 
kidneys  is  unaltered,  while  under  other  conditions  it  is  likewise 
interfered  with. 

Anatomic  Alterations. — Hypostatic  kidneys  are  generally 
enlarged.  Accordingly  the  capsule  of  the  kidney  appears  dis- 
tended on  section  of  the  organ — retracts  from  the  cut  surface.  The 
surface  of  the  kidney  appears  smooth  and  presents  a  dark-red 
color.  Frequently  the  greatly  distended  stellate  veins  upon  it  are 
conspicuous.  Upon  section  of  the  kidney,  although  the  cortex  is 
deeply  reddened  and  the  Malpighian  bodies  often  appear  as  dark-red 
granules,  the  reddish-black  discoloration  of  the  medullary  structure 
is  particularly  marked.  The  consistency  of  the  renal  tissue 
appears  increased,  and  this  fact,  in  conjunction  with  the  dark-red 
color,  has  given  rise  to  the  designation  cyanotic  induration  of  the 
kidneys. 

Microscopic  examination  discloses  great  over-distention  with  blood  of  the 
glomerular  loops  and  of  all  of  the  veins.  If  the  condition  has  existed  for 
a  long  time,  however,  striate  thickening  of  the  glomerular  capsules  and  of 
the  membrana  propria  of  the  uriniferous  tubules  takes  place.  There  may 
be  also  hyperplasia  of  the  interstitial  connective  tissue.  As  a  result  of  con- 
traction of  the  connective  tissue  the  surface  of  the  kidney  acquires  a  nodular 
appearance,  and  often  the  capsule  of  the  kidney  is  in  places  adherent  to  the 
surface  of  the  organ.  Such  a  condition  is  designated  aXso  cyanotic  contracted 
kidney.  At  times  extravasations  of  blood  have  taken  place  into  the  inter- 
stitial connective  tissue,  the  Malpighian  capsules,  and  the  uriniferous  tubules. 
At  times,  however,  only  the  remains  of  hemorrhage  are  found,  in  the  form 
of  brownish  granules  of  hemoglobin. 

Symptoms  and  Diagnosis. — Hypostasis  of  the  kidney  is 
attended  with  characteristic  alterations  in  the  urine.     The  amount 

26 


402  GENITO-URINARY  ORGANS 

of  urine  is  decreased  (below  1500  c.c.),  largely  as  a  result  of 
diminished  arterial  supply,  for  with  occlusion  of  the  renal  veins 
alone  the  secretion  of  urine  has  rather  been  found  increased.  The 
urine  is  reddisii  in  color  (high-colored,  saturated),  its  reaction  is 
strongly  acid,  and  its  specific  gravity  is  increased  (usually  above 
1020).  The  urine  contains  albumin,  but  only  in  small  amount, 
and  the  urinary  sediment  isolated  hyaline  tube-casts,  round  cells, 
and  at  times  also  a  few  red  blood-corpuscles.  Often  urates  are 
precipitated  as  a  pulverulent  deposit — so-called  brick-dust  or  lateri- 
tious  sediment.  In  addition  there  occur  edema  of  the  lower  extremi- 
ties, ascites,  and  other  manifestations  of  stasis.  In  contradistinction 
from  diffuse,  acnte  nephritis,  in  the  diagnosis  of  hypostasis  of  the 
kidney  it  is  to  be  borne  in  mind  that  the  disorder  is  generally 
induced  by  chronic  disease  of  the  heart  or  the  respiratory  organs, 
and  that  the  amount  of  albumin  and  the  number  of  tube-casts  and 
of  red  blood-corpuscles  is  usually  small.  The  course  of  Jii/postcms 
of  the  kidneys  is,  as  a  rule,  chronic,  in  accordance  with  the  causa- 
tive conditions.  Often  exacerbations  and  remissions  occur  in  con- 
formity with  the  functional  activity  of  the  right  ventricle.  Hypo- 
static kidneys  as  such  scarcely  ever  cause  death,  which,  as  a  rule, 
results  in  consequence  of  cardiac  paralysis  or  of  suffocation  from 
excessive  hydrothorax  and  hydropericardium. 

Prognosis. — The  prognosis  depends  upon  the  curability  of 
the  causative  conditions.  Usually  it  is  possible  to  increase  the 
strength  of  the  heart  and  to  overcome  the  manifestations  of  stasis 
repeatedly.  Subsequently,  however,  the  remedies  fail  to  exert  their 
effect,  and  death  is  then  unavoidal)le. 

Treatment. — The  treatment  is  the  same  as  that  for  weakness 
of  the  myocardium  (pp.  23  and  24). 

DIFFUSE  NEPHRITIS. 

ACUTE  DIFFUSE  NEPHRITIS. 

Ktiology. — Acute  diffuse  nephritis  is  either  of  infectious  or  of 
toxic  nature.  Infectious  acute  nephritis  occurs  most  commonly  in 
connection  with  infectious  diseases.  It  is  encountered  with  ]>artic- 
ular  frequency  in  the  sequence  of  scarlet  fever  and  dipiitheria, 
but  it  may  arise  also  in  the  sequence  of  other  infectious  diseases. 
Among  the  more  frequent  antecedent  conditions  may  be  mentioned 
fibrinous  pneumonia,  erysipelas,  typhoid  fever,  acute  articular  rheu- 
matism, malaria,  syphilis,  etc. 

In  relation  to  the  connection  between  infectious  diseases  and  acute  neph- 
ritis, two  possibilities  may  be  considered  ;  namely,  either  the  conveyance  of 
specific  bacteria  or  pyogenic  cocci  to  the  kidneys,  with  the  development  of 
inflammation ;  or  irritation  of  the  kidneys  in  the  elimination  of  bacterial 
poisons — toxins — through  the  kidneys.  In  accordance  with  previous  experi- 
ence, the  second  possibility  appears  to  be  the  more  commonly  effective. 


DIFFUSE  NEPHRITIS  403 

At  times  acute  nephritis  occurs  as  an  independent  infectious  dis- 
ease. I  have  observed  such  occurrence  repeatedly  in  members  of 
a  family  and  in  servants  in  endemic  distribution,  and  have  demon- 
strated the  presence  of  the  Staphylococcus  pyogenes  albus  in  the 
urine.  In  the  development  of  refrigeratory  (^rheumatic)  and  trau- 
matic acute  nephritis  exposure  to  cold  and  injury  are  probably  only 
contributing  factors,  favoring  infection  of  the  kidneys  with  bac- 
teria, among  which  the  Streptococcus  pyogenes  has  been  recognized 
in  some  cases.  Among  the  varieties  of  acute  infectious  nephritis 
belong  also  those  arising  by  extension  from  adjacent  disease.  Thus, 
acute  nephritis  not  rarely  complicates  gonorrhea,  cystitis,  pyelitis, 
or  paranephritis.  Toxic  acute  nephritis  may  be  induced  by  the  use 
of  certain  medicaments  and  poisons,  among  which  maybe  men- 
tioned cantharides,  oil  of  turpentine,  other  balsamics,  active  diu- 
retics, potassium  chlorate,  potassium  nitrate,  quinin,  sulphuric^ 
nitric,  hydrochloric,  and  carbolic  acids,  mercuric  chlorid,  etc.  In 
addition  to  the  digestive  tract,  the  injurious  substances  may  gain 
entrance  into  the  body  in  the  act  of  respiration  (oil  of  turpentine) 
through  the  air-passages,  or  by  means  of  inunctions  and  the  like. 
Irritating  ointments  containing  carbolic  acid,  pyrogallic  acid,  and 
remedies  for  scabies  are  well  adapted  to  induce  acute  nephritis. 
Possibly  that  form  of  nephritis  that  at  times  develops  in  the 
secjuence  of  chronic  cutaneous  eruptions  and  hums  of  the  shin  is  a 
variety  of  toxic  nephritis.  Acute  diffuse  nephritis  occurs  at  all 
periods  of  life.  In  children  it  develops  generally  in  connection 
with  diphtheria  and  scarlet  fever.  At  times  the  primary  disorders 
are  so  ill  defined  as  not  to  attract  attention,  and  the  acute  nephritis 
appears  to  be  an  independent  disease. 

Anatomic  Alterations. — In  the  presence  of  acute,  diffuse 
nephritis  the  kidneys  are  enlarged,  and  their  capsules  are  there- 
fore tensely  distended,  on  section  quickly  retracting  toward  the 
hilus.  The  surface  of  the  kidney  is  smooth  and  presents  a  greater 
or  lesser  number  of  small  extravasations  of  blood.  As  a  rule,  the 
surface  of  the  kidney  is  of  a  vivid,  red  color,  although  now  and 
then  pale  kidneys  are  encountered.  Upon  section  small  extrava- 
sations of  blood  are  appreciable,  particularly  in  the  cortex.  At 
times  the  Malpighian  bodies  are  conspicuous  on  account  of  in- 
crease in  size,  and  marked  distention  with  blood.  The  medulla 
of  the  kidney  often  presents  a  deep-red  color. 

On  microscopic  examination  of  the  kidneys  all  varieties  of  acute  nephritis 
probably  agree  in  the  distention  with  blood  of  the  blood-vessels  and  the  vas- 
cular loops.  Extravasations  of  blood  are  frequently  encountered,  at  times 
in  the  interstitial  connective  tissue,  at  other  times  in  the  capsule,  and  at 
still  other  times,  finally,  within  the  uriniferous  tubules.  The  involvement 
of  the  Malpighian  bodies,  the  interstitial  connective  tissue,  and  the  epithe- 
lium of  the  uriniferous  tubules,  in  the  inflammatory  process,  is  susceptible 
of  wide  variations.  Often  the  cavity  of  the  capsule  is  filled  with  an  albu- 
minous fluid,  which  has  in  part  displaced  the  loops  of  blood-vessels  from 


404  GENITO-URINARY  ORGANS 

the  inner  surface  of  the  capsule.  At  times  concentric  thickenings  of  the 
capsule,  resembling  the  layers  of  an  onion,  are  appreciable,  greatly  dimin- 
ishing the  cavity  of  the  capsule,  and  at  the  same  time  compressing  the  vas- 
cular convolution.  Cell-niulti])lication  has,  however,  taken  place  also 
between  the  individual  vascular  loops.  The  nuclei  of  these  loops  are  them- 
selves increased  in  number,  here  and  there  in  a  state  of  fatty  degeneration, 
and  in  places  the  vessels  are  occluded  by  thrombi.  Under  such  circum- 
stances the  condition  is  designated  gloinerulonephrUls,  and  these  alterations 
are  observed  with  particular  frequency  in  connection  with  scarlet  fever.  More 
or  less  marked  fatty  degeneration  has  taken  place  in  the  epithelial  cells  of  the 
convoluted  uriniferoHS  tubules.  If  the  epithelial  cells  exhibit  a  marked  ten- 
dency to  desquamation,  the  condition  has  been  described  as  acute  desqua- 
mative  nephritis.  Frequently  numerous  uriniferous  tubules  are  filled  with 
tube-casts.  Other  tubules  contain  numerous  round  cells.  Such  a  condi- 
tion has  also  been  described  as  acute  catarrhal  nephritis.  The  interstitial 
connective  tissue  of  the  kidneys  contains  collections  of  round  cells,  which  at 
times  may  be  so  large  as  to  be  visible  to  the  unaided  eye  as  small  nodules. 
This  condition  has  been  designated  also  acute  bjmphomatous  nephritis.  In 
the  different  varieties  of  acute  diffuse  nephritis  at  times  one  kind,  and  at 
other  times  other  kinds  of  alterations  preponderate.  The  question  has 
been  much  disputed  which  of  these  alterations  has  been  the  earliest.  In 
our  opinion  this  is  variable. 

Symptoms  and  Diagnosis. — Acute  diffuse  nephritis,  like 
most  diseases  of  the  kiduey,  is  susceptible  of  recognition  only 
from  the  alterations  in  the  urine.  Above  all,  the  urine  is  con- 
spicuous from  its  bloody  appearance  and  the  hemorrhagic  sedi- 
ment. At  times  the  urine  is  light  red  in  color,  resembling  meat- 
Avater,  but  frequently  it  is  reddisli  brown  or  brownish  black  from 
the  presence  of  methemoglobin  in  considerable  amount.  On 
microscopic  examination  of  the  urinary  sediment  red  blood-cor- 
puscles are  generally  found,  presenting  an  unaltered  appearance, 
or  frequently  a  biconvex  or  a  .spherical  shape.  At  times  ameboid 
movement  and  constrictions  are  observable.  Often  the  red  cells 
have  yielded  up  their  coloring-matter,  so  that  they  appear  as 
colorless  discs  of  double  contour — so-called  blood-shadows.  Fre- 
quently accumulations  and  collections  of  the  smallest  granules  and 
flocculi  of  blood  coloring-matter  are  observed.  Cylindric  struc- 
tures also  are  not  uncommonly  present,  ajiparently  consisting  of 
coherent  hemoglobin.  The  urinary  sediment  often  reveals  the 
presence  of  blood  by  its  brownish  color.  The  amount  of  sediment 
is  often  quite  considerable,  so  that  it  forms  a  dense  cloudy  precipi- 
tate. In  addition  to  the  red  blood-corpuscles  and  hemoglobin, 
there  occur  in  the  sediment  also  round  cells,  epithelial  cells  from 
the  uriniferous  tubules,  and  tube-casts.  The  last  are  at  times 
hyaline,  at  times  granular,  and  are  not  rarely  covered  with  round 
cells,  epithelial  cells  from  the  uriniferous  tubules,  and  red  blood- 
corpuscles  (Fig.  56). 

Although  the  presence  of  blood  in  the  urine — hematuria — is  a 
common  symptom  of  acute  nephritis,  it  is  not  unexceptional,  and 
cases  occur  in  which  the  urine  is  free  from  blood.  Under  such 
conditions  the  detection  of  albumin  in  the  urine — albuminuria — 


DIFFUSE  NEPHRITIS 


405 


and  of  tube-casts,  round  cells,  and  epithelium  from  the  uriuiferous 
tubules  in  the  urinary  sediment  is  of  special  importance.  The 
amount  of  albumin  in  the  urine  may  be  so  considerable  that  on 
boiling  and  addition  of  nitric  acid  the  urine  solidifies  into  a  firm 
coagulum.  The  average  amount  of  albumin  is  about  0.5  per  cent. 
In  addition  the  physical  properties  of  the  urine  should  be  given 
consideration  in  cases  of  acute  nephritis,  as  the  amount  of  urine  is 
diminished  (below  1500  c.c),  its  color  deepened,  and  its  specific 
gravity  increased  (about  1020).  Naturally,  hematuria  cannot 
always  be  referred  to  acute  nephritis.  Renal  hematuria  is  dis- 
tinguished from  admixture  of  blood  from  the  urinary  passages  from 


Q&M, 


Fig.  56. — Urinary  sediment  from  a  case  of  acute  nephritis  following  fibrinous  pneu- 
monia in  a  man,  42  years  old ;  containing  blood-casts,  red  blood-corpuscles,  round  cells, 
and  epithelial  cells  from  the  uriniferous  tubules  and  lower  urinary  passages ;  magnified 
275  times  (personal  observation). 

the  fact  that  the  urine  never  contains  clots  of  blood,  but  is  inti- 
mately and  uniformly  admixed  with  blood.  Renal  hematuria 
occurs  further  in^onnection  with  embolism  of-  tbe  renal  artery, 
although  this  develops  generally  in  association  with  valvular 
lesions  of  the  heart,  and  the  disorder  sets  in  suddenly  with  pain 
referred  to  the  kidney.  In  cases  of  hypostasis  of  the  kidney  the 
urine  contains  little  if  any  blood,  little  alljumin,  and  few  tube- 
casts,  and,  besides,  the  patients  generally  present  chronic  disease 
of  the  heart  or  the  respiratorv  organs.  In  cases  of  renal  hemor- 
rhage from  carcinoma  and  tuberculosis  of  the  kidney  the  amount  of 
albumin  present  in  the  urine  is  small,  as  is  also  the  number  of 
tube-casts,  both  at  times  even  being:  wantins;.  Traumatic  hemor- 
rhage  from  the  kidneys  presupposes  an  antecedent  injury. 


406  GENITO-URINARY  ORGANS 

Local  nlleralions  in  fJie  J:i(Jnei/s  arc  often  wanting  in  cases  of 
acute  nephritis.  Some  patients,  liowever,  complain  of  a  sense  of 
pressure,  of  tension,  and  of  pain  in  the  region  of  the  kidneys  and 
in  the  sacral  region.  Bimanual  palpation  of  the  kidneys  often 
fails  to  induce  the  slightest  unpleasant  effect.  A  frequent  symp- 
tom of  acute  diffuse  nephritis  is  cutaneous  edema.  This  often 
involves  the  face  earliest,  or  even  alone,  the  eyelids  particularly 
becoming  swollen,  and  giving  rise  to  remarkable  narrowing  of 
the  palpebral  fissure.  At  times  marked  edema  of  the  entire  skin 
is  the  earliest  sign  of  which  the  patient  has  taken  notice.  This 
may  reach  so  considerable  a  degree  that  the  skin  appears  distended 
to  the  point  of  rupture.  Often  accuraulation  of  JiuicJ  takes  place 
in  the  serous  cavities,  and  hydrothorax  and  ascites  particularly  are 
not  uncommon  complications.  It  is  noteworthy  that  the  patient 
generally  exhibits  marked  pallor,  and  examination  of  tlie  blood  dis- 
closes that  within  a  short  time  diminution  in  the  number  of  red 
corpuscles  and  in  the  percentage  of  hemoglobin  takes  place.  The 
pressure  in  the  aortic  system  undergoes  rapid  change,  and  the 
l)lood-pressure  increases.  As  a  result  the  aortic-diastolic  sound 
becomes  accentuated,  often  with  a  tympanitic-ringing  character, 
and  the  radial  pulse  becomes  tense.  In  explanation  of  this  mani- 
festation irritation  of  the  myocardium  by  metabolic  products  re- 
tained in  the  blood  must  be  assumed.  After  a  time  hypertrophy 
of  the  left  ventricle  develops. 

The  increased  arterial  blood-pressure  appears  with  especial  distinctness 
in pufse-tracings  (sphygmograms).  "While  the  reflux  elevation  becomes  less, 
the  first  elevation  due  to  elasticity  becomes  considerably  increased.  After 
complete  recovery  has  taken  place  these  manifestations  are  neutralized 
(Figs.  57  and  58).' 

The  bodily  temperature  may  remain  unchanged,  although  as  a 
rule   it  is  elevated.      At  times  the  temperature  reaches  39°  C. 


Fiu.  57. — Pulse-tracins  from  a  man.  22  years  old.  with  acute  refrigeratory  nephritis,  on  the 
eighth  day  of  the  disease  (personal  observation,  Zurich  clinic). 

(102.2°  F.)  and  above,  and  if  at  the  same  time  there  should  be 
abdominal  distention,  diarrhea,  and  enlargement  of  the  spleen, 
confusion  with  typhoid  fever  is  possible  ;  but.  naturally,  the  Widal 
blood-serum  reaction  will  always  be  wanting  in  cases  of  acute 
nephritis.  The  patients  c(im]ilain  frequently  of  drawing  pains  in 
the  muscles  and  the  joints.     Sleep  often  is  disturbed ;  while  the 


DIFFUSE  NEPHRITIS  407 

appetite  is  lost,  thirst  is  increased.  Not  rarely  there  are  difficulty 
in  the  evacuation  of  urine,  frequent  vesical  tenesmus,  and  pain  in 
the  act  of  micturition. 

The  duration  of  acute  nephi-itis  is  susceptible  of  great  variation. 
In  cases  of  infectious  disease — as,  for  instance,  fibrinous  pneu- 
monia— acute  nephritis  is  not  rarely  observed,  disappearing  within 


Fig.  58. — Pulse-tracing  from  the  same  patient  (Fig.  57),  after  recovery  had  taken  place, 

thirteen  days  later. 

one  or  two  days ;  and  it  is  a  remarkable  fact  that  such  speedy 
recovery  may  take  place  spontaneously  although  the  primary  dis- 
order continues  unchanged  or  is  perhaps  even  progressive.  In 
other  instances  acute  nephritis  may  persist  for  from  four  to  eight 
weeks.  Cases  also  occur  in  which  the  disease  persists  for  more 
than  eight  months,  so  that  the  condition  can  scarcely  be  designated 
acute  nephritis.  Recovery  generally  takes  place  in  such  a  way  that 
the  hematuria  becomes  less  pronounced  and  disappears  entirely  for 
a  time ;  the  albuminuria  also  slowly  subsides,  and  likewise  tube- 
casts  and  urinary  sediment  diminish,  and  finally  the  urine  is  free 
from  all  foreign  elements.  Often  increased  elimination  of  urine — 
polyuria — occurs  with  the  onset  of  recovery,  and  the  urine  may 
have  a  low  specific  gravity  (down  to  1005).  Not  at  all  rarely  it 
happens  that  exacerbations  and  remissions  in  the  disease  alter- 
nate with  each  other  repeatedly. 

The  dangers  of  acute  nephritis  consist  especially  in  suffocation 
as  a  result  of  edema  of  the  glottis  or  of  the  lungs,  or  of  excessive 
effusions  into  the  serous  cavities,  in  inflammation  of  the  skin  and 
septicemia,  in  uremia,  and  in  transformation  into  diffuse  chronic 
nephritis.  Injiammation  of  the  skin  may  occur  in  consequence  of 
marked  cutaneous  edema.  The  skin  becomes  reddened  and  rup- 
tures at  numerous  points,  so  that  edematous  fluid  escapes  ;  at  times 
erysipelas  or  gangrene  of  the  skin  develops,  and,  in  consequence, 
absorption  of  the  exciting  agents  of  inflammation,  general  septico- 
pyemia, which  may  terminate  fatally. 

Uremia  frequently  reveals  itself  earliest  by  headache  and 
vomiting,  until  other  uremic  manifestations,  particularly  uremic 
convulsions,  set  in.  The  smaller  the  amount  of  urine  eliminated, 
the  greater  is  the  danger  of  uremia.  Experience  has  shown  that 
the  causes  of  acute  nephritis  also  exert  an  influence  upon  the 
occurrence  of  uremia.     Uremia  is  unfortunately  common  in  con- 


408  GENITO-URINARY  ORGANS 

nection  with  scarlatinal  nephritis,  while  it  scarcely  ever  attends 
diphtheric  nephritis. 

The  transforination  of  acute  into  acute  chronic  nephritis  is  a 
rare  occurrence.  Under  such  circumstances  the  symptoms  of 
acute  chronic  parenchymatous  nephritis  usually  develop  at  first, 
witii  diminished  secretion  of  dark  urine  of  increased  specific 
gravity,  containing  a  large  amount  of  albumin  and  fattily  degen- 
erated elements  in  the  urinary  sediment  (fatty  granules  upon 
tube-casts,  fatty  granular  cells,  fattily  degenerated  epithelial 
cells),  together  with  marked  cutaneous  edema.  Gradually  the 
symptoms  of  secondary  contracting  kidney  may  be  superadded. 
Then  the  edema  disappears,  the  urine  becomes  excessively  al)un- 
dant  (above  2000  c.c),  with  a  low  specific  gravity,  a  small 
amount  of  albumin,  and  a  scanty  urinary  deposit.  Frequently 
death  results  from  uremia. 

Prognosis. — Acute  nephritis  is  ahvavs  a  serious  disease.  Xo 
remedy  with  even  an  approximately  reliable  action  is  known,  and, 
besides,  uremia  may  set  in  at  any  moment  and  bring  grave  dangers. 
The  possibility  of  transformation  into  chronic  nephritis  is  but 
small,  so  that  the  prognosis  is  not  materially  made  worse  thereby. 

Treatment. — No  medicament  capable  of  exerting  a  curative 
influence  upon  acute  nephritis  is  as  yet  known.  Astringents  (also 
known  as  styptics  or  hemostatics)  are  without  effect  upon  either 
the  hematuria  or  the  albuminuria,  and  also  fuchsin,  brombenzol, 
and  strontium  lactate,  which  have  been  recommended  to  diminish 
the  eliminaticm  of  albumin,  are  without  any  effect.  Recovery  from 
acute  nephritis  can  therefore  be  brought  about  only  through 
appropriate  dietetic  measures.  The  patient  should  remain  con- 
stantly in  bed  as  long  as  hematuria  and  albuminuria  are  demon- 
strable, for  an  equable  temperature  is  always  essential  for  patients 
suffering  from  disease  of  the  kidneys,  as  also  is  bodily  rest,  for 
hematuria  and  albuminuria  may  be  aggravated  as  a  result  of 
incautiously  getting  out  of  bed  and  walking  around.  A  tepid 
bath  at  a  temperature  of  28°  R.  (35°  C. — 95°  F.),  morning  and 
evening,  is  useful.  The  patient  should  remain  in  the  bath  for 
fifteen  minutes,  and  is  then  dried  with  a  warm  towel,  puts  on 
a  warm  shirt,  and  returns  to  bed,  which  likewise  has  been  pre- 
viously warmed  by  hot-water  bottles.  Sudden  cooling  of  the  body 
is  always  markedly  injurious  for  persons  suffering  from  disease  of 
the  kidneys.  The  bath-room  should  therefore  be  so  situated  that 
the  patient  need  not  pass  through  cold  apartments  to  enter  the 
bath. 

A  milk-diet  is  the  best  for  the  patient,  as  milk  is  both 
nutritious  and  easily  digested,  acts  as  a  diuretic,  and  does  not 
irritate  the  kidneys.  Well-boiled  milk  should  be  preferred,  as 
it  is  better  borne  and  less  readily  undergoes  fermentation  in  the 
gastro-intestinal  canal,  and  from  one  and  a  half  to  two  quarts 


DIFFUSE  NEPHRITIS  409 

should  be  given  daily,  care  being  taken  that  the  railk  be  swallowed 
slowly  in  small  amounts  at  short  intervals.  Should  the  patient 
exhibit  a  distaste  for  milk,  it  may  be  mixed  with  weak  tea  or 
coifee  or  with  beef-broth.  All  irritating  articles  of  food  should 
be  avoided,  as,  for  instance,  strong  coffee,  strong  tea,  strong  alco- 
holics, sharp  condiments,  vinegar,  etc.  Some  meat,  particularly 
white  meat,  may  be  permitted,  and  is  without  influence  upon  the 
excretion  of  proteids.  ISIashed  potatoes  and  rice-pap,  oatmeal- 
gruel  with  milk,  and  stewed  fruit  may  be  allowed.  If  symp- 
toms of  uremia  appear,  they  should  be  treated  according  to  the 
directions  given  on  page  400. 

In  the  presence  of  marked  cutaneous  edema  incisions  or  punc- 
tures should  be  made  into  the  skin,  if  diaphoretic  measures  (injec- 
tions of  pilocarpin,  hot-air  bath,  hot  bath)  have  not  secured  the 
desired  result.  If  the  edematous  skin  becomes  inflamed,  cata- 
plasms containing  mercuric  chlorid  (1.0  :  1000)  or  aluminum  acetate 
(1.0  :  100)  should  be  applied. 

CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Anatomic  Alterations. — Chronic  parenchymatous  nephritis 
is  designated  also  large  ivhite  kichiey  on  account  of  the  appearance 
of  the  diseased  organ.  The  kidney  is  considerably  enlarged,  and 
its  capsule  is  tense  and  is  readily  stripped  from  the  surface  of 
the  organ.  The  surface  of  the  kidney  is  smooth,  and  presents  a 
light  butter-yellow  color.  Upon  section  of  the  kidney  the  renal 
cortex  also  presents  a  butter-yellow  color,  while  the  medullary 
structure  is  characterized  by  a  red  color.  If  the  cut  surface  be 
scraped  with  the  blade  of  a  knife,  a  fatty  deposit  is  made. 

Microscopic  examination  of  the  kidney  discloses  particularly  marked  fatty 
degeneration  of  the  epithelial  cells  of  the  convoluted  uriniferous  tubules, 
which  are  largely  converted  into  fatty  granular  cells.  Fatty  degenerative 
processes  occur  also  in  the  vascular  loops  of  the  Malpighian  bodies,  although 
in  lesser  degree.  That  the  conditions  present  are  inflammatory  and  not 
merely  degenerative  processes  will  be  recognized  from  the  fact  that  collec- 
tions of  round  cells  are  present  here  and  there  in  the  interstitial  connective 
tissue.     The  uriniferous  tubules  are  often  tilled  with  tube-casts. 

Ktiology. — Little  of  a  definite  nature  is  known  with  regard 
to  the  causes  of  chronic  parenchymatous  nephritis.  The  condi- 
tion is  usually  an  independent  disease,  as  cases  in  which  the  affec- 
tion has  developed  from  an  antecedent  acute  nephritis  are  ex- 
tremely uncommon.  Infectious  and  toxic  influences  are  the  prin- 
cipal causative  factors.  Thus,  the  disease  has  been  observed  in 
the  sequence  of  malarial  fever,  pulmonary  tuberculosis,  syphilis, 
chronic  suppuration,  lead-poisoning,  excessive  indulgence  in  alcohol. 
The  patients  are  usually  adults. 

Symptoms,  Diagnosis,  and  Prognosis. — Of  all  of  the 
symptoms  the  alterations  in    the    urine    are  the  most  important. 


410  GENITO-URINARY  ORGANS 

The  urine  is  increased  in  amount,  although  on  long-continued 
observation  this  may  be  found  almost  normal  for  days.  The 
urine  is  dark  reddish-yellow  or  yellowish-red  in  color,  with  an 
increased  specific  gravity  (above  1020).  The  amount  of  albiuniii 
in  the  urine  is  often  quite  considerable  (up  to  5  per  cent,  and 
more).  Generally  the  urinary  sediment  is  abundant,  and  on 
microscopic  examination  it  is  found  to  be  made  up  of  tul)e-casts, 
round  cells,  and  epithelial  cells  from  the  uriniferous  tubules.  Of 
particular  importance  is  the  presence  of  numerous  fattily  degen- 
erated cells,  fatty  graiudar  cells,  as  well  as  fat-drops  u})on  tube- 
casts.  The  patients  are  conspicuous  on  account  of  pallor  of  the 
skin,  and  accordingly  the  blood  is  deficient  in  red  corpuscles  and 
hemoglobin.  Marked  cutaneous  edema  is  present,  and  the  face 
in  consequence  appears  puffy  and  distorted.  Also,  the  serous 
membranes  are  frecpiently  filled  with  transudates.  The  disease 
generally  begins  insidiously,  and  often  progressive  pallor  and 
cutaneous  edema  are  the  earliest  conspicuous  manifestations. 
Elevation  of  temperature  does  not  occur  except  in  the  presence 
of  complications.  Increase  in  arterial  blood-pressure  takes  place, 
although  it  is  by  no  means  so  constant  as  in  association  with 
acute  nephritis  and  contracted  kidney.  Most  patients  complain 
of  loss  of  appetite  and  irregularity  in  the  action  of  the  bowels. 

The  co?fr,s-e  of  the  disease  is  generally  chronic,  and  at  times 
extends  over  several  years.  Occasionally  acute  exacerbations 
occur,  in  which  the  urine  contains  blood  and  entirely  resembles 
that  observed  in  acute  nephritis.  These  exacerbations  may  in 
some  cases  occur  with  such  frequency  and  persist  for  so  long  a 
time  that  the  condition  has  been  spoken  of  as  chronic  hemorrhagic 
ncpliritis.  Recovery  is  almost  impossible.  Surgeons  have  re- 
ported isolated  instances  in  which  recovery  took  place  after  the 
removal  of  sujipurating  parts.  In  some  cases  death  ensues  from 
progressive  exhaustion.  In  others  it  results  from  excessive  edema, 
which  may  give  rise  to  asphyxia,  cardiac  para/ysis,  edema  of  the 
lunr/s  or  of  the  glottis.  It  may  also  be  induced  by  inflammation 
and  gangrene  of  the  skin,  with  consecutive  septicopyemia  second- 
ary to  marked  edema  of  the  skin. 

At  times  chronic  i)arenchymatous  nephritis  passes  into  second- 
ary contracted  kidney  in  consequence  of  hyperplasia  of  the  inter- 
stitial connective  tissue.  Under  such  circumstances  the  amount 
of  urine  becomes  increased,  and  may  even  exceed  the  daily 
amount  passed  in  health.  The  color  of  the  urine  becomes  light 
yellow,  the  specific  gravity  falls  below  1015,  and  the  amount 
of  albumin  in  the  urine  diminishes  until  only  traces  can  be  de- 
tected. The  amount  of  urinary  sediment  also  becomes  small, 
and  the  fattily  degenerated  cells  become  less  and  less  numerous. 
The  cutaneous  edema  disappears,  while  hypertrophy  of  the  lefl 
ventricle  progressively  develops,  with  a  hard,  wiry  pulse.     The 


DIFFUSE  NEPHRITIS  411 

patients  not  rarely  die  in  consequence  of  uremia,  which  is  quite 
unusual  in  association  with  pure  chronic  parenchymatous  ne- 
phritis. 

Treatment. — The  treatment  for  chronic  parenchymatous  ne- 
phritis is  the  same  as  that  for  acute  nephritis  (pp.  408  and  409). 
Nothing  can  be  accomplished  with  drugs.  The  greatest  import- 
ance should  be  attached  to  the  mode  of  life.  Causal  treatment  is 
indicated  in  cases  of  syphilis  or  lead-poisoning,  and  will  then  con- 
sist in  the  administration  of  potassium  iodid  (5.0  :  200 — 75  grains  : 
Q^  fiuidounces;  15  c.c. — 1  tablespoonful — thrice  daily).  Sup- 
puration should  be  controlled  as  speedily  as  possible,  and  if  by 
no  other  means  by  removal  of  diseased  parts. 

CHRONIC  INTERSTITIAL  NEPHRITIS. 

Anatomic  Alterations. — Chronic  interstitial  nephritis  is 
so  designated  from  its  chronic  course,  and  is  attended  particularly 
with  inflammatory  hyperplasia  of  the  interstitial  connective  tissue. 
As  a  rule,  but  by  no  means  invariably,  the  hyperplastic  connec- 
tive tissue  undergoes  contraction  after  a  time,  as  a  result  of  which 
the  kidneys  are  reduced  in  size.  From  this  fact  is  derived  the 
name  contracted  kidney.  As  the  surface  of  the  kidney  is  generally 
uneven  and  nodular,  the  condition  is  spoken  of  also  as  granular 
atrophy  of  the  kidneys.  Severed  varieties  of  contracted  kidney  must 
be  distinguished  accordingly  as  the  process  is  primary  or  second- 
ary, and,  if  primary,  whether  juvenile  or  senile  {arteriosclerotic). 

Some  clinicians  make  a  distinction  further  between  embolic  contracted 
kidney  and  hypostatic  contracted  kidney.  In  embolic  contracted  kidney  con- 
nective-tissue hyperplasia  occurs  in  the  sequence  of  embolism  of  the  renal 
artery.  Should  several  emboli  be  present  in  the  kidney,  the  organ  acquires 
a  multinodular,  irregular  surface  and  an  atrophic  appearance.  The  condi- 
tion is  almost  always  observed  in  association  with  valvular  disease  of  the 
heart.  It  has  already  been  pointed  out  that  connective-tissue  hyperplasia 
and  contraction  may  occur  in  connection  with  hypostasis  of  the  kidney. 
These  two  varieties  are  to  be  distinguished  from  cardiac  conlracted  kidney, 
because  in  this  condition  the  kidney  is  involved  only  secondarily  in  the  se- 
quence of  disease  of  the  heart,  and  the  affection  does  not  represent  an  inde- 
pendent disease  of  the  kidney. 

Pi'imary  or  genuine  juvenile  contracted  kidney  occurs  in  indi- 
viduals less  than  forty  years  old.  The  capsule  of  the  kidney  is 
often  so  firmly  adherent  to  the  surface  of  the  organ  that  it  can  be 
removed  only  with  some  laceration  of  the  kidney.  The  kidneys 
are  conspicuous  for  their  smallness,  at  times  being  reduced  as 
much  as  one-third  in  size  and  weight.  The  surface  of  the  kidney 
is  multinodular,  and  the  individual  prominences  may  be  of  approx- 
imately the  same  size.  These  consist  of  relatively  healthy  renal 
tissue,  while  the  depressions  between  them  result  from  contracted 
connective  tissue.  Here  and  there  cystic  cavities  of  varying  size, 
filled  with  water,  at  times  with  colloid  fluid,  are  present.     The 


412  GENITO-rniyARY  ORGANS 

surface  of  the  kidney  is  grayish  red  in  color.  On  section  it  will 
be  found  that  the  kidney  cuts  with  peculiar  resistance  and  almost 
like  leather.  Tiie  cut  section,  like  the  surface,  is  grayish  red  in 
color.  The  cortical  tissue  is  diminished  in  amount,  being  in  places 
contracted  to  a  band  one  millimeter  thick.  The  medullary  sub- 
stance, together  with  the  calices  of  the  kidney,  is  also  diminished. 
The  pelvis  of  the  kidney  appears  rather  dilated. 

On  7)iieroscoplc  examination  the  changes  in  the  inferstidal connective  tissue 
are  especially  conspicuous.  There  will  be  found  here  foci  of  round-cell 
accumulation,  which  form  preferably  in  the  neighborhood  of  the  Malpigh- 
ian  bodies,  and  the  interstitial  connective  tissue  besides  appears  increased, 
so  that  the  uriniferous  tubules  are  separated  from  one  another  by  intervals 
of  unusual  size.  The  Malpighian  bodies  also  participate  in  the  connective- 
tissue  hyperplasia,  and  their  capsules  are  transformed  into  thick,  striated, 
and  cellular  membranes.  With  progressive  increase  of  connective  tissue 
the  capsular  cavity  becomes  reduced,  and  finally  complete  connective-tissue 
obliteration  of  the  capsule  takes  place.  The  uriniferous  tubules  do  not  re- 
main uninvolved  in  the  processes  described.  Often  they  are  constricted  off 
by  connective-tissue  hyperplasia,  at  times  in  garland-like  arrangement  in 
several  divisions.  Should  fluid  collect  in  the  constricted  portions,  cystic 
cavities  form  that  are  appreciable  microscopically.  For  this  purpose  it  is 
naturally  necessary  that  they  .shall  have  attained  considerable  dilatation. 
Only  in  recent  years  has  attention  been  called  to  changes  in  the  blood-vessels, 
which  indicate  that  juvenile  contracted  kidney  is  in  all  probability  of  vas- 
cular origin.  These  consist  in  thickening  of  the  intima  of  small  arteries, 
which  in  places  has  led  to  closure  of  the  lumen  of  the  vessel — chronic  oblit- 
erating endarteritis.  In  addition,  thickeningof  the  muscular  layer  and  depo- 
sition of  hyaline  masses  take  place. 

Senile  or  arteriosclerotic  contracted  kidney  results  from  arterio- 
sclerosis of  the  renal  artery  and  its  branches,  and  is  therefore 
of  vascular  origin.  It  generally  develops  in  advanced  life, 
because  arteriosclerosis  is  a  disease  of  that  period.  Also,  in 
cases  of  arteriosclerotic  contracted  kidney  the  capsule  of  the 
organ  is  often  adherent  to  the  surface  of  the  kidney.  The  sur- 
face of  the  kidney  appears  uneven  and  nodular,  and  often 
exhibits  cystic  cavities.  The  color  of  the  kidney  is  rather  gray 
than  red.  On  section  of  the  kidney  its  tough  consistency  is 
less  marked  than  in  the  juvenile  contracted  kidney.  The  cortex 
in  places  is  greatly  diminished.  ^Microscopic  examination  dis- 
closes particularly  that  the  inter.stitial  connective-tissue  hy]ier- 
pla.sia  is  not  uniform,  but  is  focal  in  distribution,  and  that  calcifi- 
cation is  often  present  in  the  partially  destroyed  Malpighian 
bodies. 

Secondary  contracted  kidney  develops  from  chronic  parenchyma- 
tous nephritis  as  a  result  of  a  gradual  washing  out  with  the  urine 
of  the  fattily  degenerated  epithelial  cells  from  the  convoluted 
uriniferous  tubules,  so  that  the  tul)ules  undergo  partial  collapse, 
while  interstitial  connective-tissue  hyperplasia  preponderates. 
Microscopically  the  secondary  contracted  kidney  is  characterized 
by  the  preservation  of  a  yellowish  or  yellowish-gray  color,  the 


DIFFUSE  NEPHRITIS  413 

yellow  areas  corresponding  to  fattily  degenerated  epithelial  cells 
in  the  convoluted  uriniferous  tubules,  and  the  gray  areas  to  the 
hyperplastic  interstitial  connective  tissue.  At  times  the  kidney 
acquires  a  yellowish,  mottled  appearance,  so  that  it  has  been  de- 
scribed as  a  spotted  or  mottled  contracted  kidney.  Further,  the  sec- 
ondary contracted  kidney  may  be  unchanged  in  size  and  possess  a 
smooth  surface,  so  that  the  interstitial  connective-tissue  hyper- 
plasia will  be  disclosed  only  on  microscopic  examination. 

Ktiology. — Chronic  interstitial  nephritis  results  in  conse- 
quence of  infectious,  toxic,  or  involutional  influences.  The  infec- 
tious varieties  of  contracted  kidney  include  those  that  develop  in  the 
train  of  infectious  diseases,  such  as  malaria  and  syphilis.  Urocys- 
titis  and  gonorrhea  also  at  times  cause  contracted  kidney.  Toxic 
contracted  kidney  develops  in  consequence  of  the  action  of  lead  as 
the  so-called  plumbic  contracted  kidney.  Disorders  of  metabolism, 
and  particularly  gout,  may  also  be  mentioned  as  causes.  Arterio- 
sclerotic contracted  kidney  is  a  result  of  involutional  processes  that 
attend  advanced  age,  but  nothing  further  is  known  with  regard  to 
the  actual  processes  concerned.  In  cases  of  secondary  contracted' 
kidney  the  causes  of  the  antecedent  chronic  parenchymatous  neph- 
ritis must  be  taken  into  consideration,  and  these,  as  has  been  men- 
tioned, are  usually  of  infectious  or  toxic  nature.  Contracted  kid- 
ney occurs  with  exceptional  rarity  in  children,  and  it  is  then  usu- 
ally a  secondary  condition.  Further,  it  is  at  times  impossible  to 
elicit  a  cause  for  the  disease.  Sometimes  the  disorder  is  hereditary, 
possibly  because  a  morbid  condition  of  weakness  of  the  walls  of 
the  blood-vessels  is  inherited.  Exposure  to  cold  and  to  wet,  and 
indulgence  in  alcohol,  create  a  liability  to  the  disease,  and  were  con- 
sidered by  earlier  clinicians  as  the  actual  causes. 

Symptoms  and  Diagnosis. — Contracted  kidney  usually 
develops  insidiously,  and  is  unattended  with  cutaneous  edema. 
It  is  therefore  not  uncommon  for  the  disease  to  be  discovered 
quite  accidentally  on  examination  of  the  urine.  Naturally  there 
are  certain  suspicious  symptoms  that  should  always  stimulate  an 
experienced  and  cautious  clinician  to  subject  the  urine  to  careful 
examination.  Among  these  may  be  mentioned  palpitation  of  the 
heart,  persistent  head.ache,  impairment  of  vision,  repeated  epis- 
taxis,  persistent  hoarseness,  frequent  vomiting,  obstinate  eczema, 
and  itching  of  the  skin.  The  majority  of  these  symptoms  are  of 
uremic  nature.  Also,  the  sudden  occurrence  of  eclamptic  convul- 
sions or  of  cerebral  hemorrhage  is  often  dependent  upon  chronic 
interstitial  nephritis. 

The  urine  is  increased  in  amount,  and  instead  of  from  1500  to 
2000  c.c.  the  daily  amount  may  reach  from  3000  to  6000  c.c.  and 
even  more.  Often  the  patients  are  aroused  from  sleep  by  the  fre- 
quent desire  to  evacuate  the  bladder.  The  urine  is  pale  yellow 
in  color,  and  often  exhibits  a  distinct  tendency  toward  a  greenish 


414  GENITO-URINARY  ORGANS 

tint.  Frequently  the  urine  is  slightly  turbid,  and,  after  shaking,  the 
froth  is  retained  upon  its  surface  for  a  long  time,  a  property  that 
is  often  possessed  by  urine  containing  abnormal  ingredients  (albu- 
min, sugar,  biliary  coloring-matter).  Tiie  specific  gravity  of  the 
urine  is  diminished  (below  1015),  at  times  as  low  as  1002.  The 
reaction  of  the  urine  is  feebly  acid.  Only  a  slight  sediment  is 
precipitated  from  the  urine,  and  not  rarely  none  at  all,  and  this 
upon  microscopic  examination  is  found  to  contain  hyaline  and 
granular  tube-casts  of  varying  width.  The  amount  of  all)umin 
present  is  always  small,  but  albumin  may  also  he  absent  for  days 
and  weeks.  Under  such  conditions  it  is  possible  to  confound  the 
disease  with  simple  polyuria — diabetes  insipidus — for  in  this  disor- 
der also  the  amount  of  urine  is  increased  and  the  specific  gravity 
is  diminished  ;  but  polyuria  is  unattended  with  the  alterations  in  the 
heart  and  the  pulse,  and  usually  also  with  the  retinal  changes  that 
attend  contracted  kidney.  Confusion  with  glycosuria — diabetes 
mellitus — is  scarcely  possible,  because  in  this  condition  the  specific 
gravity  of  the  urine,  which  is  increased  in  amount,  is  abnormally 
high.  At  times  irritative  states  of  the  urinary  passages,  as,  for  in- 
stance, catarrh  of  the  urinary  bladder,  gonorrhea,  tuberculosis,  cause 
increased  secretion  of  urine,  with  a  reduction  in  specific  gravity,  but 
the  urinary  sediment  will  not  contain  tube-casts,  if  albumin  be 
present  its  amount  will  correspond  with  the  admixture  of  pus  or 
of  blood  with  the  urine,  and  changes  in  the  circulatory  apparatus 
and  in  the  retina  do  not  occur. 

The  alterations  in  the  circulatory  apparatus  take  a  conspicuous 
part  in  the  clinical  picture  of  contracted  kidney.  Hypertrophy  of  the 
left  ventricle  develops  with  great  constancy  in  conjunction  with  a 
generally  slight  dilatation.  The  hypertrophy  of  the  heart-muscle 
gives  rise  to  a  heaving  and  resistant  apex-beat,  and  an  accentu- 
ated, frequently  tympanitic  and  ringing  diastolic  (second)  aortic 
sound.  Dilatation  of  the  left  ventricle  gives  rise  to  increased 
extent  of  the  apex-beat,  and  to  its  displacement  outside  the  left 
mammillary  line  and  below  the  left  fifth  intercostal  space. 
Further,  after  a  time  dilatation  and  hypertrophy  of  the  right 
ventricle  frequently  also  develop. 

The  connection  between  contracted  kidnetj  and  hypertrophy  of  the  myocar- 
dium of  fhe  left  side  of  tlie  heart  has  not  yet  been  definitely  established. 
The  conditions  found  in  acute  nephritis  indicate  that  also  here  irritative 
influences  due  to  toxic  substances  retained  in  the  blood  must  be  thought  of. 
Endarteritic  alterations  similar  to  those  that  occur  in  the  contracted  kidney 
itself  have,  however,  also  been  observed  in  the  blood-vessels,  and  it  is  con- 
ceivable that  the  hypertrophy  of  the  heart-muscle  is  attributable  to  these. 
The  earlier  view  that  the  hypertrophy  of  the  heart-muscle  is  a  result  of 
destruction  of  numerous  blood-vessels  in  the  diseased  kidneys  has  properly 
been  abandoned,  for  hypertrophy  of  the  heart  does  not  develop  even  after 
amputation  of  both  lower  extremities,  although  a  far  more  extensive  vascu- 
lar area  is  removed,  and  the  blood-pressure  in  the  aortic  system  is  in  con- 
sequence greatly  increased. 


DIFFUSE  NEPHRITIS  415 

The  hypertropliy  of  the  left  side  of  the  heart  is  appreciable 
to  the  patient  as  distressing  palpitation,  which  usually  occurs 
particularly  after  mental  and  physical  excitement,  and  after  the 
ingestion  of  stimulating  fluids  (coffee,  tea,  alcohol).  Reference 
has  already  been  made  to  this  complaint  as  one  of  the  suspicious 
symptoms  of  contracted  kidney.  The  hypertrophy  of  the  muscle 
of  the  left  side  of  the  heart  is  manifested  further  in  unusual  hard- 
ness of  the  radial  pulse,  in  correspondence  with  the  increased 
blood-pressure  in  the  aortic  system.  The  pulse  often  feels  like  an 
irou  wire,  whence  it  has  been  designated  also  the  iviry  'pulse.  A 
trained  hand  can  frequently  detect  the  presence  of  contracted 
kidney  from  feeling  the  radial  pulse. 

In  the  indse-tracing  or  sphygmogram  the  abnormal  increase  in  blood- 
pressure  is  exhibited  in  the  small  size  of  the  reflux  elevation,  and  the  un- 
usually marked  character  of  the  first,  elasticity-elevation  (Fig.  59).  Further, 
the  blood-pressure  in  the  radial  artery  has  been  measured  by  means  of  the 
sphygmomanometer  of  v.  Basch,  and  it  has  been  found  to  be  as  high  as  244 
mm.  of  mercury  instead  of  160. 


Fig.  59. — Pulse-tracing  from  the  right  radial  artery  in  a  ease  of  chronic  interstitial  nephritis 
in  a  man  27  years  old  (personal  observation,  Zurich  clinic). 

Retinal  changes  occur,  according  to  my  experience,  in  one-fifth 
of  all  the  cases.  Particularly  characteristic  are  yellowish  spots 
around  the  macula  lutea,  which  result  from  sclerosis  of  the  axis- 
cylinders  in  the  retina,  and  larger  spots  in  the  neighborhood  of 
the  optic  papilla,  which  depend  principally  upon  fatty  degenera- 
tion of  the  granular  layers.  These  alterations  constitute  the  con- 
dition of  albuminuric  retinitis.  In  addition,  there  are  frequently 
also  swelling  of  the  optic  papilla  and  retinal  hemorrhages,  venous 
hyperemia,  and  tortuosity  of  the  veins.  The  mode  of  origin  of 
these  nutritive  disturbances  in  the  retina  is  unknown.  Visual 
acuity  may  be  preserved  in  spite  of  the  retinal  changes,  but  fre- 
quently complaint  is  made  of  obscuration  and  impairment  of 
vision. 

Persons  wnth  contracted  kidneys  often  present  unusual  pallor, 
which  is  dependent  upon  diminution  in  the  number  of  red  blood- 
corpuscles  and  in  the  percentage  of  hemoglobin.  Rapid  emacia- 
tion generally  takes  place,  and  the  patients  tire  readily.  The  skin 
usually  feels  extremely  dry,  and  exhibits  a  tendency  to  desquama- 
tion. Obstinate  eczema  also  is  frequently  present.  The  bodily- 
temperature    exhibits  no   noteworthy  alteration.      Although    the 


416  GENITO- URINARY  ORGANS 

appetite  is  impaired,  the  sense  of  thirst  is  increased,  obviously  in 
consequence  ot'  tlie  increased  elimination  of  urine,  and  often  the 
jxitient  complains  of  dryness  of  the  mouth  and  of  stickiness  of  the 
tontjue. 

The  course  of  contracted  kidney  is  chronic,  and  not  rarely  extends 
over  several  years.  Most  patients  die  of  uremia,  which  may  set  in 
suddenly  and  may  terminate  fatally  within  a  short  time,  or  in 
other  instances  be  repeated  from  time  to  time.  Occasionally 
cerebral  heuiorrhage — encephahrrhagia — occurs  in  the  first  place, 
because  in  cases  of  contracted  kidney  the  blood-vessels  of  the  brain 
likewise  often  undergo  degeneration,  and  also  because  hyper- 
trophy of  the  muscle  of  the  left  side  of  the  heart,  and  the  resulting 
increase  in  the  blood-pressure  in  the  arteries,  increase  the  liability 
to  rupture  of  blood-vessels.  At  times  symptoms  of  iceakness  of 
the  heart-muscle  appear.  Gallop-rjiythm  becomes  audible  over  the 
heart,  hypostatic  edema  develops,  and  finally  cardiac  paralysis  and 
asphyxia.  Xow  and  again  acute  exacerbations  in  the  inflammatory 
process  in  the  kidneys  occur,  and  the  urine  contains  blood  and 
resembles  that  of  acute  nephritis.  There  is  also  a  great  tendency 
to  inflammatorij  processes  in  various  organs,  and  death  not  rarely 
results,  particularly  from  pneumonia. 

Prognosis. — Contracted  kidney  is  an  incurable  disease,  and 
the  prognosis  is  accordingly  grave.  Albuminuric  retinitis  is  an 
unfavorable  symptom,  for  death  usually  follows  within  two  years. 

Treatment. — The  treatment  is  the  same  as  that  for  acute 
nephritis.  Well-to-do  patients  may  be  recommended  a  sojourn 
in  Southern  climates  in  order  to  escape  the  dangers  of  fluctuating 
and  cold  weather.  Particularly  a  residence  on  the  borders  of  the 
African  desert  (Helouan)  often  has  a  remarkably  favorable  influ- 
ence upon  the  albuminuria. 

PURULENT  NEPHRITIS. 

Ktiology. — Purulent  inflammation  of  the  kidney  probably 
occurs  only  as  a  result  of  the  entrance  of  pyogenic  micro- 
organisms into  the  kidney.  Chemic  irritation  and  suppuration  in 
the  kidney  scarcely  occur  in  human  beings.  In  addition  to  the 
Streptococcus  pyogenes  and  the  Staphylococcus  pyogenes  aureus 
and  albus,  the  Bacterium  coli  ])articularly  has  been  shown  to 
be  capable  of  exciting  suppuration,  and  this  organism  appears 
to  play  the  principal  part  in  the  etiology  of  suppuration  of  the 
kidneys.  Pneumoniacocci  and  typhoid-bacilli  have  also  been 
found  in  isolated  instances.  Bacteria  can  gain  entrance  into  the 
kidneys  in  any  of  three  ways :  namely,  through  the  urinary 
passages,  the  blood-vessels,  or  the  lymphatics.  Infection  of  the 
kidneys  by  way  of  the  urinary  passages  is  probably  the  most 
common,    and    just    under    such    conditions    the    Bacterium    coli 


PURULENT  NEPHRITIS  417 

appears  to  be  the  exciting  agent  with  particular  frequency. 
Gonorrhea  and  stricture  of  the  urethra,  cystitis,  and  pyelitis  are 
not  rarely  attended  with  purulent  nephritis.  The  disorder  occurs 
with  especial  frequency  in  association  with  renal  and  vesical  cal- 
culi. Urinary  stasis  of  whatever  origin  greatly  favors  infection 
of  the  kidneys.  Not  rarely  this  develops  in  the  sequence  of  sur- 
gical operations  upon  the  bladder  or  the  urethra — as,  for  instance, 
after  the  introduction  of  sounds  or  catheters — and  the  condition 
has  been  designated  surgical  kidney.  Naturally  the  danger  of 
infection  is  particularly  great  if  most  scrupulous  disinfection  of  the 
instruments  employed  is  not  practised. 

Infection  of  the  kidneys  by  way  of  the  arteries  occurs  in  con- 
nection with  suppuration  of  the  kidneys  of  embolic  origin.  The 
suppuration  associated  with  idcerative  endocarditis  is  best  known, 
but  similar  processes  are  probably  operative  when  purulent  ne- 
phritis develops  in  the  sequence  of  other  infectious  diseases.  The 
lymphatics  will  constitute  the  medium  of  infection  particularly 
when  inflammatory  processes  in  the  neighborhood  (paranephritis) 
have  extended  to  the  kidney.  Infectious  agents  may  be  intro- 
duced into  the  kidney  directly  through  wounds  inflicted  by  in- 
struments (dagger,  knife,  gun),  but  it  should  be  borne  in  mind 
that  suppuration  of  the  kidney  may  occur  also  in  consequence  of 
closed  injuries,  as,  for  instance,  a  fall,  a  blow,  or  a  contusion  of 
the  loin,  and  even  after  violent  concussion  of  the  body.  At 
times  it  is  impossible  to  elicit  a  cause  for  suppuration  of  the 
kidney — cry  mitogenetic  purulent  nephritis.  Some  patients  then 
attribute  the  condition  to  cold,  but  on  careful  inquiry  they  are 
usually  able  to  give  no  definite  information  with  regard  to  this 
factor.  In  any  event,  refrigeratory  (rheumatic)  suppuration  of 
the  kidney  can  be  accepted  only  in  the  sense  that  the  exposure  to 
cold  alone  did  not  excite  the  suppuration,  but  merely  favored 
infection  of  the  kidneys  through  alterations  in  the  circulation  and 
the  resulting  diminished  powers  of  resistance  of  the  tissues.  Sup- 
purative nephritis  is  an  uncommon  disease,  which  usually  occurs 
after  the  fifteenth  year  of  life,  and  is  more  common  in  men  than 
in  women. 

Anatomic  Alterations. — In  advanced  cases  of  purulent 
nephritis  little  or  none  of  the  tissue  of  the  kidney  will  be  left^ 
so  that  the  capsule  of  the  organ,  which  frequently  is  thickened^ 
consists  of  a  sac  filled  with  pus.  Under  such  circumstances  the 
condition  may  be  designated  also  pyonephrosis,  or,  if  the  pelvis 
of  the  kidney  has  actively  participated  in  the  inflammatory  pro- 
cess, suppui'ative  pyelonephritis.  In  less  advanced  cases  the  kidney 
contains  one  or  more  small  foci  of  suppuration,  which  here  and 
there  exhibit  a  tendency  to  coalesce.  The  suppuration  generally 
begins  in  the  form  of  small,  scarcely  visible  submiliary  and  mili- 
ary abscesses,  the  coalescence  of  which  gives  rise  to  larger  and 

27 


418  GEMTO-  Ulil^A  li  Y   OIK iA SS 

larger  acciinuilations  of  i)ii.s.  In  the  presence  of  embolic  abscesses 
of  the  kidney  the  infective  enibolns  can  be  fonnd  at  the  center  of 
the  lesion.  The  cellnlar  elements  in  the  immediate  vicinity  of  tl»e 
enibolns  exhibit  necrosis,  and  the  peripheral  boundaries  of  this 
necrotic  area  are  surrounded  ))y  collections  of  round  cells.  Also, 
the  uriniferous  tubules  are  filled  Avith  bacteria,  and  not  rarely 
form  within  the  papillie  of  the  kidney  straight  grayish-white 
lines  converging  toward  the  apex  of  the  papillae.  Purulent 
nc])hritis  is  at  times  bilateral,  for  both  embolic  processes  and 
iniiauimatory  processes  arising  by  extension  from  the  bladder 
are  quite  well  capable  of  involving  both  kidneys  in  the  morbid 
process. 

Symptoms  and  Diagnosis. — In  the  diagnosis  of  purulent 
nephritis  three  groups  of  symptoms  particularly  are  important, 
namely,  those  of  general  septicopyemia,  local  alterations  in  the 
kidneys,  and  changes  in  the  urine.  The  disease,  like  all  other 
supi)nrative  processes,  is  attended  with  fever,  which  at  times  is 
interrupted  by  chills.  The  fever  freqnently  exhibits  a  remitting 
type.  There  is  a  marked  tendency  to  frequent,  profuse,  and  debili- 
tating sweats.  The  patients  generally  soon  become  pallid,  lose 
appetite,  complain  of  increased  thirst,  and  not  rarely  suffer  from 
diarrhea.  The  local  alterations  in  the  kidneys  consist,  in  the  first 
place,  in  renal  pain,  which  may  occur  spontaneously  or  be  induced 
by  pressure  in  the  loin.  Frequently  the  diseased  organ  can  be 
felt  on  bimanual  palpation,  and  it  will  be  found  to  be  enlarged. 
At  times  fluctuation  is  appreciable. 

As  always  in  palpating  the  abdominal  organs,  the  patient  should  lie  with 
the  head  dependent  and  the  lower  extremities  flexed  at  the  hips  and  the 
knees,  in  order  to  relax  the  abdominal  walls.  The  examination  should  be 
made  only  with  warm  hands,  in  order  to  avoid  the  rigidity  of  the  abdom- 
inal muscles  induced  by  cold.  If  necessary,  the  hands  should  be  immersed 
in  warm  water.  The  patient  should  be  engaged  in  conversation  during  the 
examination,  in  order  to  divert  his  attention  therefrom.  It  may  also  be 
serviceable  to  have  the  patient  lie  upon  the  healthy  side. 

Naturally,  foci  of  suppuration  in  the  kidney  must  have  attained 
-a  certain  size  before  they  can  give  rise  to  appreciable  enlargement 
of  the  organ,  and  therefore  such  increase  will  not  be  present  when 
the  collections  of  pus  are  small.  The  associated  pyelitis  usually 
present  may  take  a  considerable  share  in  causing  enlargement  of 
the  kidney.  It  may  also  happen  that  the  kidney  is  at  times  larger 
and  at  other  times  smaller,  accordingly  as  the  pus  has  free  exit 
into  the  bladder  or  undergoes  stagnation. 

In  the  presence  of  purulent  nephritis  the  urine  contains  pus — 
pyuria — as  soon  as  the  purulent  accumulation  has  ruptured  into 
the  urinary  passages.  Under  such  conditions  the  presence  of 
albumin  can  i)e  demonstrated  in  the  urine,  to  an  amount  corre- 
sponding with  the  amount  of  })us.     Larger  amounts  of  albumin 


PURULENT  NEPHRITIS  .     419 

and  tube-casts  will  be  present  in  the  urine  only  when  a  diffuse 
inflammation  of  the  kidney  has  been  superadded  to  the  purulent 
nephritis.  Blood  is  not  rarely  present  in  the  urine  if  blood-vessels 
are  perforated  in  the  process  of  destruction  of  the  kidney.  The 
presence  of  desquamated  renal  tissue — renal  sequestra — is  particu- 
larly significant ;  but  this  occurrence  is  uncommon.  The  sequestra 
may  at  times  attain  the  size  of  a  pigeon's  ego^,  and  on  microscopic 
examination  exhibit  the  structure  of  renal  tissue.  Often  the 
amount  of  urine  is  increased  in  consequence  of  reflex  irritation 
of  the  renal  nerves.  Under  such  circumstances  the  urine  is  light 
yellow  in  color  and  of  a  low  specific  gravity.  The  urine  often 
undergoes  alkaline  fermentation.  Kot  rarely  the  patients  complain 
of  vesical  tenesmus  and  of  pain  in  the  evacuation  of  urine. 

The  diagnosis  of  suppuration  of  the  kidney  may  be  extremely 
difficult,  because  in  the  presence  of  small  encapsulated  foci  of  pus 
in  the  kidney  local  alterations  in  the  kidney  and  in  the  urine  may 
be  absent.  Should  pyuria  be  present,  the  possibility  of  tubercu- 
losis of  the  urinary  organs  should  be  considered,  although  this 
would  be  attended  with  the  presence  of  tubercle-bacilli  in  the 
urine.  Purulent  nephritis  is  distinguished  from  suppuration  in  the 
urinary  passages  by  means  of  the  local  alterations  in  the  kidney. 

The  course  of  sujjpuration  of  the  kidney  may  be  acute,  subacute, 
or  j3hronic,  and  in  the  last-named  event  it  may  extend  over  many 
months.  Among  the  complications  renal  colic  should  first  be  men- 
tioned. This  results  in  consequence  of  temporary  obstruction  of 
the  ureter  by  plugs  of  pus  or  exfoliated  renal  tissue,  with  the 
development  of  acute  urinary  stasis  in  the  affected  ureter  and 
pelvis  of  the  kidney.  The  patients  then  usually  complain  of 
sudden,  severe  pain  in  one  loin,  are  at  times  seized  with  a  chill 
and  vomiting,  and  the  bodily  temperature  rises  to  a  higher  level. 
The  urine  becomes  diminished  in  amount  and  often  quite  clear, 
because  it  is  secreted  by  the  free  healthy  kidney.  In  consequence 
of  acute  urinary  stasis  in  the  pelvis  of  the  kidney — acute  hydro- 
nephrosis— the  diseased  organ  either  becomes  palpable,  or,  if  it  has 
previously  been  palpable,  it  becomes  increased  in  size.  As  soon 
as  the  obstruction  to  the  flow  of  urine  is  removed  the  pain  ceases, 
the  temperature  declines,  and  often  remarkably  large  amounts  of 
urine  are  evacuated,  the  fluid  being  now  again  purulent  and  turbid. 
Should  the  obstruction  not  be  removable,  there  will  be  danger  of 
uremia  and  urinary  septicemia. 

Among  the  less  common  occurrences  are  paralysis  of  the  lower  extrem- 
ities— urinary  paraplegia — which  has  been  attributed  to  neuritis  resulting  by 
extension  from  the  kidney. 

The  situation  becomes  extremely  grave  when  the  accumulation 
of  pus  ruptures  not  into  the  urinary  passages,  but  into  the  sur- 
rounding tissues.  Rupture  into  the  abdominal  cavity  usually  causes 
rapidly  fatal  peritonitis ;  rupture  into  the  pararenal  cellular  tissue 


420  GENITO-URINABY  ORGANS 

gives  rise  to  paranephritis.  Rupture  may  take  place  also  into  the 
stomach,  the  intestine,  the  pleural  cavity,  or,  after  the  previous 
formation  of  pleuritic  adhesions,  into  the  l)ronchial  tul)es.  At 
times  the  pus  ruptures  externally,  and  an  external  renal  fistula  is 
formed.  Under  such  conditions  extensive  burrowing  of  the  pus 
is  possible.  Long-continued  suppuration  of  the  kidney  at  times 
gives  rise  to  amyloid  disease  and  its  dangers.  At  times  death  re- 
sults in  consequence  of  progressive  exhaustion  or  of  urinary  septi- 
cemia, the  latter  resulting  from  absorption  of  bacteria  from  the 
decomposed  urine  into  the  blood. 

Prognosis. — The  prognosis  of  purulent  nephritis  has  become 
more  favorable  within  recent  years  from  an  appreciation  of  the 
fact  that  the  disease  is  a  surgical  disorder  which  cannot  be  influ- 
enced by  internal  remedies.  Nevertheless  the  disease  is  still  a 
serious  one. 

Treatment. — The  single  possible  means  by  which  an  accumu- 
lation of  pus  in  the  kidney  can  be  removed  consists  in  neplurotomy 
or  nephrectomy.  Nephrotomy  will  suffice  when  the  diseased  organ 
still  contains  considerable  healthy  tissue.  Otherwise  nephrectomy 
should  be  performed,  and  the  diseased  kidney  removed  from  the 
body. 

EMBOLIC  INFARCTION  OF  THE  KIDNEY.       > 

!^tiology. — Embolic  infarction  of  the  kidney  occurs  princi- 
pally in  connection  with  disease  of  the  aortic  or  mitral  valve,  in 
consequence  of  the  detachment  of  small  thrombotic  vegetations 
that  gain  entrance  with  the  blood-current  into  the  renal  artery^  or 
more  commonly  into  small  branches  thereof,  and  there  become 
impacted.  Only  rarely  is  the  condition  dependent  upon  detached 
echinococcus-vesicles,  or  fragments  of  tumors  of  the  myocardium, 
upon  detached  tlirombi  from  arteriosclerotic  areas  in  the  aorta  or 
from  aortic  aneurysms,  or  upon  thrombi  from  the  pulmonary 
veins. 

Anatomic  Alterations. — Emboli  gain  entrance  most  com- 
monly into  the  blood-current  through  the  left  renal  artery,  because 
this  arises  from  the  abdominal  aorta  at  less  nearly  a  right  angle 
than  the  right  renal  artery.  Only  rarely  does  an  embolus  remain 
lodged  in  the  trunk  of  the  renal  artery.  When  it  does,  necrosis 
occurs  in  almost  the  entire  portion  of  the  kidney  cut  off  from  its 
blood-supply.  As  a  rule,  emboli  are  swept  into  the  smaller 
branches  of  the  renal  artery,  where  they  give  rise  to  the  formation 
of  wedge-shaped  renal  infarcts.  These  reach  the  surface  of  the 
kidney  with  a  broad  base,  while  their  apices  are  directed  toward 
the  medullary  aspect.  The  wedge-shaped  area  cut  off  from  its  blood- 
supply  undergoes  speedy  coagulation-necrosis,  and  acquires  a  yel- 
lowish-gray color.     Its  boundaries  appear  blood-stained  from  the 


AMYLOID  KIDNEY  421 

presence  of  emigrated  red  blood-corpuscles.  Subsequently  fatty 
degeneration  and  absorption  of  the  area  may  take  place,  so  that 
only  a  small,  superficial,  depressed  cicatrix  remains  upon  the  sur- 
face of  the  kidney.  If  the  kidney  is  the  seat  of  multiple  emboli, 
it  may  acquire  a  multinodular  appearance  suggestive  of  contracted 
kidney,  and  the  condition  has  been  designated  arteriosolerotic  con- 
tracted kidney.  At  times  calcification  takes  place  in  renal  infarcts. 
Not  rarely  both  kidneys  are  the  seat  of  emboli. 

Symptoms  and  Diagnosis. — Embolism  of  the  kidney  may 
be  recognized  generally  from  the  sudden  occurrence  of  pain  in  the 
loin.  Pressure  in  the  same  situation  discloses  also  tenderness.  A 
chill,  followed  by  elevation  of  temperature  and  vomiting,  often  occurs 
in  consequence  of  reflex  irritation.  The  urine  becomes  bloody — 
hematuria — and  not  rarely  contains  also  tube-casts  and  rather  more 
albumin  than  corresponds  to  the  amount  of  blood.  In  addition 
the  demonstration  of  a  source  of  embolism,  thus  generally  a  valvu- 
lar lesion  of  the  heart,  will  be  important  in  the  diagnosis.  The 
symptoms  may  disappear  in  the  course  of  a  few  days,  although  re- 
currences are  possible  at  any  moment. 

Prognosis. — Embolic  infarction  of  the  kidney  is  not  a  serious 
disorder,  providing  the  embolus  does  not  contain  bacteria  nor  pos- 
sess infectious  properties,  so  that  suppuration  of  the  kidney  is  not 
to  be  feared. 

Treatment. — Rest  in  bed  and  a  milk-diet  should  be  prescribed, 
an  ice-bag  applied  to  the  affected  loin,  and  if  the  pain  be  intense 
a  subcutaneous  injection  of  morphin  may  be  given. 

AMYLOID  KIDNEY. 

etiology. — The  causes  of  amyloid  kidney  are  the  same  as 
those  of  amyloid  disease  of  other  organs — chronic  wasting  dis- 
charges and  cachectic  conditions  of  all  kinds  ;  as  examples  may  be 
mentioned  suppuration  of  bones  and  joints,  chronic  diarrhea,  pul- 
monary tuberculosis,  syphilis,  malaria,  and  carcinoma.  Only 
rarely  does  amyloid  kidney  develop  without  appreciable  cause.  As 
the  same  causative  factors  are  also  capable  of  inducing  chronic 
parenchymatous  nephritis,  it  will  be  understood  that  both  diseases 
occur  together  with  great  frequency. 

Anatomic  Alterations. —  Uncomplicated  -amyloid  kidney  is 
extremely  rare.  In  the  presence  of  diffuse  amyloid  degeneration 
the  kidneys  present  a  pale-yellow  or  whitish  appearance,  whence 
the  designation  waxy  kidney.  The  kidneys  are  increased  in  size. 
Their  capsule  is  readily  detached  from  the  surface  of  the  organ, 
and  the  latter  presents  a  smooth  appearance.  The  consistency  of 
the  organ  is  increased.  The  renal  tissue  at  times  presents  an  ap- 
pearance as  if  frozen,  so  that  it  can  be  shaved  from  sections  of  the 
kidney.     Thin  sections  appear  translucent  in  transmitted   light. 


4-J.2  GEMTO-L'HiyAHY   (JllUASS 

If  a  solution  of  iodin  and  potassium  iodid  be  poured  upon  the  cut 
surface,  tliis  will  assume  a  mahogany-brown  tint.  In  the  majority 
of  cases  the  large  white  kidney  already  described  will  be  encoun- 
tered, and  the  presence  in  this  of  areas  of  amyloid  degeneration 
can  be  demonstrated  from  the  appearance  of  the  mahogany-brown 
color  on  addition  of  the  solution  of  iodin  and  potassium  iodid. 

On  microscopic  examination  the  amyloid  tissue  is  characterized  by  its 
waxy  luster  and  its  swollen  and  structureless  appearance.  It  yields,  besides, 
the  amyloid  reactions  with  the  solution  of  iodin  and  potassium  iodid,  with 
the  solution  of  iodin  and  dilute  sulphuric  acid  and  methyl-violet  described 
on  pp.  343  and  344.  The  vascular  loops  in  the  ^Ialj)ighian  bodies  are  attacked 
earliest;  then  the  efferent  vessels  and  the  straight  vessels  are  involved;  and 
finally  also  the  capillaries  between  the  uriniferous  tubules  aud  in  the  medulla 
of  the  kidney,  the  capsules  of  the  Malpighian  bodies  themselves,  the  mem- 
brana  propria,  and  the  epithelial  cells  of  the  uriniferous  tubules. 

Generally  other  organs  also  are  the  seat  of  amyloid  degenera- 
tion, particularly  the  spleen,  the  cortex  of  the  adrenal  bodies,  the 
liver,  and  the  intestines. 

Symptoms  and  Diagnosis. — In  the  presence  of  uncompU- 
cated  amyloid  kidney  the  amount  of  urine  is  normal  or  slightly 
increased.  The  urine  is  pale  yellow  in  color,  and  its  specific 
gravity  is  diminished  (from  1010  to  1015).  The  urine  generally 
contains  considerable  albumin  (up  to  20  grams — 300  grains — 
daily),  although  isolated  instances  are  on  record  in  Avhich  albumin- 
uria was  absent  throughout.  The  urinary  sediment  is  generally 
slight,  and  at  times  contains  remarkably  wide  cylinders  of  Avaxy 
luster.  Some  tube-casts  may  also  yield  the  amyloid  reaction, 
although  this  is  not  distinctive  of  amyloid  disease  of  the  kidneys, 
as  it  may  occur  also  in  connection  with  diffuse  nephritis.  As  a 
rule,  there  is  marked  edema.  The  primary  disorder  itself  \\'\\\ 
cause  pallor  of  the  skin.  Death  usually  takes  place  in  consequence 
of  progressive  exhaustion  or  of  excessive  edema.  Should  amyloid 
disease  of  the  kidneys  exist  in  association  with  chronic  parenchy- 
matous nephritis,  the  symptoms  of  the  latter  will  be  the  more  con- 
spicuous, and  there  is  no  infallible  symptom  Ijy  which  the  amyloid 
degeneration  can  be  recoo;nized  with  anv  deo-ree  of  certaintv. 
Amyloid  kidney  will  be  present,  in  all  probability,  if  increased 
size  and  consistency  of  the  spleen  and  the  liver  indicate  amyloid 
degeneration  of  these  organs.  Should  the  intestine  be  involved  in 
amyloid  disease,  diarrhea  also  will  be  present. 

Prognosis. — The  prognosis  of  amyloid  disease  of  the  kidney 
is  uutavoralile,  as  recovery  appears  impossil)le. 

Treatment. — In  the  first  place,  the  same  dietetic  regulations 
should  i)e  prescribed  as  in  diffuse  nephritis  (pp.  408  and  409). 
Among  drugs,  iron  and  iodin  have  been  employed,  as,  for  instance : 

R  Sirup  of  iron  iodid, 

Simple  sirup,  each,  50.0  (lo  fluidounces). — M. 

Dose :  10  c.c.  (a  dessertspoonful)  thrice  daily. 


CARCINOMA   OF  THE  KIDNEY  423 

CARCINOMA  OF  THE  KIDNEY. 

Ktiology. — Carcinoma  of  the  kidney  may  be  either  primary 
or  secondary.  Often  ilo  cause  is  ascertainable  for  primary  carci- 
noma of  the  kidney.  The  patients  often  attribute  the  condition  to 
traumatism.  Possibly  renal  calculi  also  may  give  rise  to  carcinoma 
of  the  kidney.  Experience  has  shown  that  men  are  attacked 
oftener  than  women.  Although  carcinoma  of  the  kidney  occurs 
with  particular  frequency  after  the  fiftieth  year  of  life,  it  consti- 
tutes an  exception  as  compared  with  carcinoma  in  other  organs 
from  the  fact  that  it  has  been  observed  in  numerous  instances  also 
in  children  within  the  first  five  years  of  life.  Secondary  carci- 
noma of  the  kidney  results  either  through  direct  extension  of  the 
new-growth  from  the  neighborhood,  or  through  metastatic  dis- 
semination from  remotely  situated  organs.  Not  rarely  it  develops 
in  the  sequence  of  carcinoma  of  the  testicle,  even  if  the  diseased 
organ  was  removed  many  years  previously. 

Anatomic  Alterations. — Primary  carcinoma  of  the  kidney 
generally  develops  only  in  one  kidney,  whereas  secondary  car- 
cinoma frequently  appears  in  both  organs.  In  cases  of  secondary 
carcinoma  of  the  kidney  the  new-growths  generally  consist  in  cir- 
cumscribed nodules,  whereas  in  cases  of  primary  carcinoma  diiFuse 
infiltration  of  the  kidney  takes  place.  Under  these  conditions  the 
kidney  may  be  greatly  increased  in  size  and  weight,  although  it 
usually  retains  its  shape  in  considerable  degree.  On  section  of  the 
kidney  the  new-growth  will  at  times  present  a  dense  fibrous  appear- 
ance, with  a  deficiency  of  fluid,  at  other  times  a  soft  and  medul- 
lary appearance,  and  at  times  be  traversed  by  cavities  containing 
colloid  material,  so  that  a  distinction  is  commonly  made  between 
fibrous  carcinoma  (scirrhus),  medullary  carcinoma,  and  colloid  car- 
cinoma (alveolar  or  gelatinous  carcinoma).  The  neoplastic  tissue  is 
generally  grayish  white  or  yellowish  white  in  color.  At  times 
it  contains  numerous  blood-vessels,  and  then  presents  a  reddish 
appearance.  Also,  blood-vessels  may  rupture  and  copious  extrava- 
sations of  blood  take  place  into  the  carcinomatous  tissue,  and 
these,  after  having  existed  for  a  considerable  time,  acquire  a 
reddish-brown,  chocolate-like  appearance.  The  carcinomatous 
cells  are  considered  as  offspring  of  the  epithelial  cells  of  the 
uriniferous  tubules.  Extensive  careinomata  of  the  kidney  not 
rarely  cause  displacement  of  adjacent  organs  (liver,  stomach, 
spleen,  intestine). 

Symptoms  and  Diagnosis. — Carcinoma  of  the  kidney  may 
remain  unrecognized  so  long  as  it  does  not  undergo  disintegration, 
and  thereby  give  rise  to  alterations  in  the  urine,  or  so  long  as  demon- 
strable enlargement  of  the  kidney  is  not  present.  Under  the  most 
favorable  circumstances  latent  carcinoma  may  then  be  suspected  from 
progressive  emaciation  and  pallor,  although  doubt  may  remain  as 


424  GENITO-URINARY  ORGANS 

to  the  scat  of  the  disease.  Carcinoma  of  the  kidney  frequently 
gives  rise  to  hematuria,  resulting  from  ])erforation  of  blood-vessels 
in  the  process  of  disintegration  of  the  carcinomatous  tissue.  Hema- 
turia in  advanced  life,  occurring  without  demonstrable  cause,  should 
always  arouse  suspicion  of  carcinoma  of  the  kidney.  The  hemor- 
rhage may  be  abundant,  persist  for  a  long  time,  be  repeated  at 
short  intervals,  and  as  a  result  cause  alarming  anemia  and  serious 
loss  of  strength.  Examination  of  the  urinary  sediment  may  prove 
of  importance,  for,  although  it  is  true  that  carcinoma-cells  pre- 
sent in  themselves  nothing  peculiar,  it  Avill  nevertheless  always 
be  highly  suspicious  if  many  cells  are  present,  and  particularly 
cell-groups  with  multiple  nuclei.  The  bloody  urine  is  often  evacu- 
ated without  discomfort.  In  some  cases,  however,  attacks  of  renal 
colic  occur  which  result  from  temporary  obstruction  of  the  ureter 
by  blood-clots  of  considerable  size,  or  by  aggregations  of  cells. 
The  patients  often  complain  persistently  of  severe  pain  in  the  loin, 
which  is  particularly  prone  to  occur  at  night  and  disturb  sleep.  At 
times  the  patients  are  able  to  walk  only  with  the  body  bent  forward, 
at  the  same  time  avoiding  with  fear  all  possible  rotation  or  flexion 
of  the  vertebral  column.  Pressure  in  the  loin  is  generally  painful. 
If  the  kidney  has  become  increased  in  size  in  consequence  of  car- 
cinomatous proliferation,  it  at  times  gives  rise  to  a  considerable 
visible  enlargement  in  the  loin  and  of  the  abdomen.  In  diagnosis 
tlie  detection  on  palpation  of  a  tumor  in  the  loin,  which  is  usually 
nodular,  painful,  and  hard,  is  important,  although  carcinoma  of 
the  kidney  also  may  be  fluctuating.  If  the  carcinoma  is  of  small 
size,  it  may  at  times  be  possible  to  reach  it  with  the  fingers  by 
having  the  patient  lie  upon  the  healthy  side  of  the  body  and  make 
deep  inspirations  while  bimanual  palpation  of  the  kidney  is  prac- 
tised. 

It  is  by  no  means  always  easy  to  determine  with  certainty  that  an  ab- 
dominal tumor  is  of  renal  origin.  It  should  be  noted,  in  the  first  place, 
that  the  tumor  in  question  is  situated  in  the  loin  or  has  arisen  therefrom. 
Besides,  renal  tumors  do  not  undergo  displacement  with  the  respiratory 
movements,  and  generally  retain  the  bean-shaped  form  of  the  kidney. 
They  are  separated  from  the  lower  border  of  the  liver  by  a  tympanitic  zone 
on  percussion,  because  the  transverse  colon  passes  between  the  two  organs 
Finally,  a  sausage-shaped  body  usually  passes  over  its  anterior  surface  from 
below  upward,  and  this  may  from  time  to  time  be  seen  to  be  the  seat  of 
peristaltic  movement.  This  corresponds  with  the  ascending  or  descending 
colon  displaced  from  its  normal  situation.  It  becomes  especially  distinct 
on  insufflation  of  the  rectum  with  air,  and  on  jjercussion  it  then  yields  a 
tympanitic  note. 

Extensive  tumors  of  the  kidney  displace  the  liver,  the  dia- 
phragm, the  lungs,  and  the  heart  upward,  and  as  a  result  cause 
marked  dyspnea,  palpitation  of  the  heart,  and  a  sense  of  constric- 
tion. Pressure  upon  the  stomach  and  the  intestines  induces 
vomiting  and  irregularity  in  bowel-movement.     Patients  with  car- 


CYSTIC  KIDNEY  425 

cinoma  of  the  kidney  usually  undergo  rapid  emaciation  and 
become  exceedingly  pale.  Death  results,  as  a  rule,  within  a  year 
in  consequence  of  carcinomatous  marasmus.  At  times  complica- 
tions arise,  such  as  7'upture  of  the  new-growth  into  the  abdominal 
cavity,  into  blood-vessels,  or  externally.  Rupture  into  the  ab- 
dominal cavity  is  generally  followed  by  rapidly  fatal  peritonitis, 
while  rupture  externally  gives  rise  to  an  external  renal  fistula, 
and  rupture  into  the  blood-vessels  to  hypostatic  edema.  Pressure 
upon  adjacent  nerves  may  give  rise  to  intercostal  neuralgia  or 
paralysis  of  one  lower  extremity.  The  tumor  may  also  penetrate 
the  vertebral  canal  through  the  intervertebral  foramina,  and  cause 
spinal  pressure-paralysis. 

Prognosis. — The  prognosis  of  carcinoma  of  the  kidney,  like 
that  of  carcinoma  in  other  organs,  is  unfavorable.  The  only  hope 
for  recovery  depends  upon  early  operation. 

Treatment. — Nothing  can  be  accomplished  in  the  treatment 
of  carcinoma  of  the  kidney  by  means  of  internal  remedies.  When 
the  diagnosis  has  been  established  no  time  should  be  lost  in  the 
performance  of  nephrectomy.  If  the  appropriate  time  for  opera- 
tion has  been  neglected,  or  if  the  patient  declines  operation,  all 
that  remains  is  symptomatically  to  administer  narcotics  for  the 
relief  of  severe  pain,  and  styptics  for  the  control  of  profuse  hem- 
orrhage. In  addition,  an  effort  should  be  made  to  sustain  the 
strength  by  means  of  a  nutritious  diet. 

In  addition  to  carcinoma,  sarcoma  and  adenoma  of  the  kidney  possess 
clinical  significance.  Both  of  these  are  indistinguishable  from  carcinoma 
during  life.  Sarcoma  of  the  kidney  is  frequently  of  secondary  origin  and 
bilateral.  Sarcoma  of  the  kidney  is  observed  also  in  children  in  the  first 
five  years  of  life.  At  times  sarcomata  contain  transversely  striated  muscu- 
lar fibers  (striocellular  myosarcoma).  Adenoma  of  the  kidney  not  rarely 
originates  from  displaced  elements  of  the  adrenal  gland. 


CYSTIC  KIDNEY. 

Anatomic  Alterations. — Cystic  kidney  consists  in  a  trans- 
formation of  one  or  often  both  kidneys  into  a  multilocular  struc- 
ture, which  may  attain  considerable  proportions  and  greatly  dis- 
place adjacent  organs.  The  individual  cavities  frequently  contain 
fluid,  at  times  also  colloid  material  in  which,  remarkably,  no  urea, 
and  at  most  uric  acid,  can  be  demonstrated.  At  times  scarcely  a 
trace  of  renal  tissue  can  be  recognized.  The  walls  of  the  indi- 
vidual cavities  consist  of  connective  tissue.  Their  inner  surface 
is  lined  with  longitudinally  arranged  endothelial  cells ;  here  and 
there  collections  of  epithelial  cells  are  present.  The  condition  is 
probably  always  a  congenital  one,  and  it  is  often  associated  with 
other  malformations  (harelip,  club-foot,  absence  of  the  renal  pelvis 
and  the  ureter,  absence  of  the  duct  of  Botal). 


420  GENITO-URINARY  ORGANS 

Opinions  are  divided  as  to  the  7node  of  origin  of  conrjenilal  cystic  kidney. 
According  to  the  view  of  some,  it  results  from  urinanj  staitis  during  fetal  life, 
which  may  occur  either  in  consequence  of  inflammatory  alterations  in  the 
jjapillse  of  the  kidney  and  obstruction  of  the  uriniferoiis  tubules,  or  from 
failure  in  the  establishment  of  proper  relations  between  the  glomeruli  and 
the  convoluted  uriniferous  tubules  and  the  deeper  uriniferous  tubules  in 
the  development  of  the  kidney.  Others  consider  the  condition  as  a  neo- 
plastic one  {cyst adenoma).  Both  views  are  supported  by  certain  evidence: 
the  first,  for  instance,  by  the  fact  that  congenital  cystic  kidney  has  been 
observed  in  association  with  congenital  phimosis,  and  the  second  by  the 
fact  that  congenital  cystic  kidney  may  suddenly  increase  in  size  in  advanced 
life.     Possibly  both  modes  of  development  occur. 

Htiolog"y. — Nothing  is  known  with  rejrard  to  the  causes  of 
congenital  cystic  ki(hiev.  At  times  several  members  of  the  same 
family  are  victims  of  the  disease. 

Symptoms  and  Diagnosis.— At  times  cystic  kidneys  attain 
stich  considerable  proportions  during  fetal  life  as  to  cause  obstruc- 
tion to  labor,  and  delivery  can  be  effected  only  after  embryotomy. 
In  other  instances  the  children  are  born  alive,  but  })resent  so  large 
a  renal  tumor  that  death  soon  occurs  from  asphyxia  and  cardiac 
paralysis.  In  still  other  instances  no  symptoms  at  all  are  present 
for  years.  Then,  however,  the  kidney  becomes  greatly  enlarged, 
and  gives  rise  to  symptoms  and  dangers  in  consequence.  Such 
observations  naturally  often  give  the  impression  that  the  disorder 
has  developed  after  birth.  In  the  diagnosis  the  demonstration 
of  a  tumor  of  the  kidney  is  important  in  the  first  place,  and  this 
has  been  discussed  on  p.  424.  The  tumor  itself  often  presents  a 
nodular  surface,  so  that  it  may  be  readily  mistaken  for  carcinoma 
of  the  kidney.  In  contradistinction  from  abscess  and  echinococcus 
of  the  kidney  and  hydronephrosis,  fluctuation  is,  as  a  rule,  not 
elicitable.  Should  exploratory  puncture  be  decided  upon,  it  is 
important  to  bear  in  mind  that  tirea  will  not  be  found  in  the  fluid. 
The  urine  is  frequently  unaltered,  although  hematuria  may  occur 
periodically.  Albuminuria  is  not  rarely  observed.  The  patients 
complain  principally  of  a  sense  of  tension  and  of  pain  in  the  loin 
and  in  the  abdominal  cavity.  Dis])lacenient  upwai^d  of  the  liver, 
the  spleen,  the  diaphragm,  the  lungs,  and  the  heart  gives  rise  to 
dyspnea  and  jDalpitation  of  the  heart,  and  at  times  causes  death 
by  suffocation  or  paralysis  of  the  heart.  Some  patients  die  from 
uremia  in  consequence  of  suppression  of  urine.  Cystic  kidneys 
may  also  rujiture,  and  thereby  occasion  serious  dangers,  as,  for 
instance,  perfoi'ative  peritonitis. 

Prognosis. — The  prognosis  of  cystic  kidney  is  unfavorable, 
because  the  cysts  have  a  tendency  to  undergo  enlargement,  and 
in  conscfjuence  to  be  attended  with  various  dangers. 

Treatment. — The  treatment  of  cystic  kidney  is  surgical,  and 
consists  in  puncture  of  the  cysts  or  nephrectomy,  although  the  latter 
should  be  performed  only  when  the  other  kidney  is  healthy  with 
certainty. 


ECHINOCOCCUS  OF  THE  KIDNEY  427 

ECHINOCOCCUS   OF  THE  KIDNEY* 

Ktiology. — With  regard  to  the  cause  of  echinococcns  of  the 
kidney,  the  statements  made  upon  pp.  350  and  351  concerning 
echinococcns  of  the  liver  are  applicable.  Human  beings  acquire 
echinococci  by  swallowing  the  ova  of  the  tapeworm  of  the  dog — 
Taenia  echinococcns.  An  explanation  is  wanting  for  the  fact  that 
echinococcus-C3^sts  develop  at  times  in  one  and  at  other  times  in 
another  organ. 

Anatomic  Alterations. — Echinococcns  of  the  kidney  is 
generally  unilateral,  and,  as  experience  has  shown,  it  is  most  com- 
monly situated  upon  the  left  side.  The  cyst  is  unilocular,  and  it 
may  at  times  be  larger  than  an  adult  head,  and,  in  addition  to 
fluid,  contain  also  daughter-cysts  and  granddaughter-cysts.  Cho- 
lesterin-plates  and  crystals  of  uric  acid,  calcium  oxalate,  and 
ammonio-magnesium  phosphate  may  frequently  be  demonstrated 
in  the  fluid.  At  times  only  small  remnants  of  renal  tissue  are 
still  present.     The  healthy  kidney  often  appears  hypertrophied. 

Symptoms  and  Diagnosis. — The  diagnosis  of  echinococcus 
of  the  kidney  is  absolutely  certain  only  when  echinococcus-vesicles, 
echinococcus-scolices,  or  echinococcus-hooklets  can  be  demonstrated 
in  the  urine.  This  will  be  possible  only  wdien  the  mother-cyst. has 
ruptured  and  evacuated  its  contents  into  the  pelvis  of  the  kidney. 
Under  such  conditions  symptoms  of  renal  colic  (sudden  pain, 
chill,  fever,  vomiting)  frequently  first  appear,  as  long  as  the  echi- 
nococcus-cyst  causes  obstruction  of  the  ureter.  Additional  uri- 
nary disturbances  occur  when  the  echinococcns-cyst  obstructs  the 
urethra.  At  times  the  echinococcus-cyst  is  suddenly  expelled 
forcibly  for  a  considerable  distance  with  a  loud  sound,  and  is  suc- 
ceeded by  turbid,  milky  urine  resembling  soapsuds.  Expulsion 
of  echinococcus-vesicles  with  the  urine  may  be  repeated  at  inter- 
vals of  varying  length,  and  for  a  period  of  years.  In  this  way 
natural  recovery  may  take  place.  Should  expulsion  of  echino- 
coccus-cysts  with  the  urine  not  take  place,  echinococcus  of  the 
kidney  can  be  recognized  only  when  a  tumor  of  the  kidney  has 
developed.  Should  this  be  wanting,  the  cyst  will  remain  con- 
cealed. The  tumor  of  the  kidney,  the  essential  points  in  whose 
diagnosis  have  been  stated  on  p.  424,  is  generally  nodular  and 
yields  fluctuation,  though  not  constantly.  The  differentiation 
from  cystic  kidney,  abscess  of  the  kidney,  and  hydronephrosis  is 
often  impossible.  Exploratory  puncture  may  yield  the  desired 
information  from  the  discovery  of  echinococcus-scolices  or  echino- 
coccus-hooklets in  the  fluid.  At  times  an  echinococcus-cyst  of 
the  kidney  undergoes  suppuration,  and  the  clinical  picture  may 
then  even  more  closely  simulate  that  of  abscess  of  the  kidney. 
Rupture  of  an  echinococcus  of  the  kidney  into  adjacent  organs 
(stomach,  intestine,  pleural  cavity,  lungs,  and  bronchi),  or  into 


428  GENITO-UBINARY  ORGANS 

the  abdominal  cavity,  or  externally,  may  also  take  place  at  times. 
AVlien  the  kidney  has  undergone  considerable  increase  in  size 
symptoms  of  pressure  upon  adjacent  organs  will  appear — gastric  and 
intestinal  disturbances,  dyspnea  to  the  point  of  asphyxia,  palpita- 
tion of  the  heart,  and  cardiac  paralysis. 

Prognosis. — The  prognosis  of  echinococcus  of  the  kidney  is 
not  unfavorable  if  the  disorder  is  looked  upon  as  a  surgical  one, 
and  too  nuich  time  is  not  consumed  with  internal  treatment. 

Treatment. — Echinococcus-cysts  cannot  be  destroyed  by  in- 
ternal remedies.  Injections  of  mercuric  chlorid  (1  :  1000)  into  the 
echinococcus-cyst  may  possibly  cause  death  and  contraction.  In 
the  presence  of  an  extensive  echinococcus-cyst  of  the  kidney, 
nephrotomy  or  nephrectomy  should  always  be  resorted  to,  accord- 
ingly as  considerable  healthy  renal  tissue  is  present  or  not. 


MOVABLE  KIDNEY. 

etiology. — jNIovable  kidney  occurs  with  great  frequency, 
particularly  in  pallid  and  emaciated  women.  Not  rarely  the  kid- 
ney is  forcibly  displaced  from  its  natural  situation  by  pressure, 
particularly  as  a  result  of  tight  lacing,  the  wearing  of  constricting 
waist-bands,  and  the  like.  In  men  who  from  vanity  wear  corsets  or 
tight  belts  movable  kidney  develops  in  the  same  way  as  in  women. 
At  times  movable  kidney  is  induced  by  heavy  lifting  and  persistent 
expulsive  effort,  because  the  diaphragm  as  a  result  thereof  exerts 
pressure  upon  the  kidney.  Wandering  kidney  is,  therefore,  com- 
mon in  persons  with  chronic  cough  and  constipation.  In  some 
cases  the  condition  has  been  observed  to  develop  in  the  sequence 
of  a  fall  or  a  blow  upon  or  an  injury  to  the  loin.  At  times  wander- 
ing kidney  occurs  as  a  result  of  emaciation,  as,  for  instance,  after 
protracted  febrile  disease,  or  after  reduction-cures,  ol^viously  be- 
cause as  a  result  the  capsule  of  the  kidney  likewise  yields  up  some 
of  its  fat  and  its  support  of  the  kidney  is  lost.  Occasionally 
wandering  kidney  appears  after  the  puerperium,  in  consequence  of 
relaxation  of  the  abdominal  walls  and  diminution  in  the  intra- 
abdominal pressure.  Increased  weight  of  the  kidney  may  also  give 
rise  to  wandering  kidney,  as,  for  instance,  when  the  organ  is  the 
seat  of  carcinoma  or  tuberculosis.  At  times  the  kidney  is  forcibly 
displaced  from  its  situation,  as,  for  instance,  by  tumors  of  the  liver, 
the  spleen,  the  pancreas,  or  in  consequence  of  kyphoscoliosis  of  the 
vertebral  column.  In  some  cases  nervous  influences  appear  to  be 
operative.  Thus,  movable  kidney  is  not  at  all  uncommon  in  cases 
of  tabes  dorsalis.  The  frequent  association  of  wandering  kidney 
and  diseases  of  the  female  generative  apparatus  is  likewise  often 
referred  to  the  nervous  influence  of  the  latter  upon  the  kidneys. 
There  is,  probably,  also,  a  congenital  j^t'edisposition  to  wandering 


MOVABLE  KIDNEY  429 

kidney.  The  aflPection  is  rare  in  childhood,  although  isolated 
instances  of  congenital  movable  kidney  are  on  record. 

Symptoms,  Diagnosis,  and  Anatomic  Alterations. — 
Many  persons  possess  a  movable  kidney  without  suspecting  the 
fact.  The  condition  may  be  found  accidentally  on  careful  exam- 
ination of  the  kidneys.  It  can  be  detected  with  especial  ease  if, 
with  the  abdominal  walls  relaxed,  bimanual  palpation  of  the  kid- 
neys is  practised  and  deep  inspirations  are  encouraged.  Most  com- 
monly the  right  kidney  is  movable,  and  this  is  diie  to  the  fact  that 
it  is  subjected  to  a  certain  degree  of  pressure  by  the  superimposed 
liver.  The  left  kidney  is  much  less  commonly  affected,  and  least 
commonly  both  kidneys  are  movable.  The  mobility  of  the  kidney 
may  attain  varying  degrees  of  intensity.  In  the  mildest  cases  the 
lower  extremity  of  the  kidney  can  just  be  felt  on  deep  inspiration, 
and  some  clinicians  even  believe  that  this  is  a  natural  and  not  a 
morbid  manifestation.  In  advanced  cases  the  entire  kidney  can 
be  felt,  and  be  moved  up  and  down  in  its  fatty  capsule.  In  the 
aggravated  cases  the  kidney  is  wholly  displaced  from  its  normal 
situation,  and  may  be  found  in  the  abdominal  cavity,  sometimes 
in  the  iliac  fossa  and  even  in  the  true  pelvis.  Some  clinicians 
designate  only  cases  of  the  last  kind  as  wandering  kidney  or  mi- 
g7'ating  kidney.  Under  such  circumstances  the  kidney  may  possess 
such  a  degree  of  mobility  that  it  can  be  readily  moved  to  and  fro 
in  the  abdominal  cavity.  Naturally  it  may  happen  also  that  the 
organ  becomes  adherent  in  some  abnormal  situation,  where  it  again 
becomes  immovable. 

As  a  matter  of  course,  marked  downward  displacement  of 
the  kidney  is  possible  only  when  the  organ  possesses  an  abnorm- 
ally long  mesonephron.  At  the  same  time  the  renal  artery  and 
vein  must  be  unduly  lengthened.  At  times  the  patients  them- 
selves first  notice  a  movable  body  in  the  abdomen  accidentally, 
and  come  to  the  physician  in  great  alarm,  fearing  the  presence  of 
carcinoma.  Under  such  circumstances  it  often  requires  most 
earnest  assurances  in  order  to  relieve  them  of  this  fear.  In 
other  instances  the  physician  discovers  the  readily  movable 
kidney  accidentally  in  the  course  of  an  abdominal  examination 
for  some  other  purpose.  That  the  body  is  the  kidney  will  be 
recognized  from  the  bean-shaped  form  of  the  tumor.  Its  surface 
is  smooth,  and  pressure  causes  a  dull,  painful  sensation.  At  times 
— according  to  my  experience  quite  rarely — the  loin  upon  one  side 
will  be  found  upon  inspection  to  be  depressed,  and,  on  comparison 
with  the  opposite  side,  it  will  yield  a  tympanitic  note  on  percussion, 
which  will  be  replaced  by  a  dull  percussion-note  when  the  mov- 
able kidney  has  been  restored  to  its  normal  situation. 

At  times  pulsation  of  the  renal  artery  can  be  felt  in  the  hilus  of  the  kidney. 

Not  rarely  the  patient  with  wandering  kidney  applies  to  the 


430  GENITO-URINARY  ORGANS 

physician  for  the  relief  of  various  comphiint.s,  as  the  cause  for 
which  tlie  wandering-  kidney  is  found.  Indivi(hials  with  wander- 
ino-  kidney  often  suffer  from  a  liigh  degree  of  nervousness.  Fre- 
quently, complaint  is  made  of  disagreeable  rather  than  painful 
drawing  sensations  in  the  abdominal  cavity  and  in  the  loin.  Often 
gastric  disorders  have  developed,  such  as  loss  of  appetite,  eructa- 
tion, and  vomiting.  Investigation  of  the  functions  of  the  stomach 
often  discloses  the  fact  that  the  absorption-period  for  potassium 
iodid  is  retarded,  and  that  the  motor  power  of  the  stomach  is 
diminished,  so  that  the  food  remains  in  the  stomach  for  a  consider- 
able time.  Often  the  gastric  juice  is  deficient  in  hydrochloric 
acid.  Less  commonly,  in  my  experience,  there  is  an  excess  of 
hydrochloric  acid  in  the  gastric  juice.  After  distention  of  the 
stomach  with  carbon  dioxid  the  viscus  will  be  found  at  an  un- 
usually low  level,  so  that,  in  addition  to  the  displacement  of  the 
kidney — nephroptosis — there  is  also  displacement  of  the  stomach — 
gastroptosis.  jS^evertheless,  dilatation  of  the  stomach  may  develop 
in  connection  with  \vandering  kidney  either  because,  in  the  presence 
of  right-sided  wandering  kidney,  the  pylorus  becomes  obstructed 
by  pressure  or  traction,  or  because,  in  consequence  of  anemia  and 
nervousness,  the  walls  of  the  stomach  imdergo  relaxation. 

Often,  there  is  obstinate  constipation,  which  may  increase  to  the 
decree  of  intestinal  obstruction,  and  this  mav  at  times  be  due  to 
the  pressure  exerted  by  the  movable  kidney  upon  the  bowel,  and 
at  other  times  to  atony  of  the  intestinal  musculature.  In  some 
patients  attacks  of  hepatic  colic  occur,  with  sudden  pain  in  the 
region  of  the  gall-bladder,  jaundice,  frequent  vomiting,  and  at 
times  also  fever.  The  clinical  picture  deceptively  resembles  that 
of  gall-stone  colic,  and  results  from  acute  biliary  stasis  caused 
by  pressure  or  traction  upon  the  ductus  choledochus.  Further, 
in  consequence  of  biliary  stasis  and  hypostatic  catarrh  in  the 
biliary  passages,  gall-stones  are  not  at  all  uncommon  in  association 
with  Avandering  kidney.  At  times  peculiar  attacks  occur,  which 
have  been  designated  incarceration  of  a  icandcring  I'iclnei/.  The 
patients  complain  of  severe  pain  in  the  location  of  the  wandering 
kidney,  and  the  organ  generally  is  also  extremely  sensitive  to 
touch.  The  kidney  often  is  greatly  increased  in  size,  and  as,  at  the 
same  time,  the  urine  is  diminished  in  amount,  the  enlargement  of 
the  organ  may  be  dependent  upon  urinary  stasis  and  acute  dilata- 
tion of  the  pelvis  of  the  kidney — paroxysmal  hydronephrosis. 
Fever  is  present  and  vomiting  is  frequent.  Such  a  condition  may 
develop  without  demonstrable  cause,  although  some  patients 
attribute  it  to  bodily  over-exertion  or  to  sudden  change  in  posture. 
Obviously  the  disorder  is  dependent  solely  upon  sudden  occlusion 
of  the  ureter  and  acute  urinary  stasis,  resulting  from  either  twist- 
ing of  the  kidney  about  the  long  axis  of  its  ureter  or  sudden 
displacement  downward  of  the  kidney  and  kinking  of  its  ureter. 


MOVABLE  KIDNEY  431 

Generally  the  condition  corrects  itself  in  the  course  of  a  few  days. 
At  times  it  disappears  rapidly  if  the  kidney  is  restored  to  a  more 
favorable  situation  through  the  adoption  of  a  given  position  of  the 
body  or  as  the  result  of  efforts  at  reposition.  The  occurrence  of 
the  change  for  the  better  is  often  manifested  by  the  evacuation 
of  large  amounts  of  urine  within  a  short  time.  At  the  same  time 
the  kidney  becomes  greatly  reduced  in  size.  It  is  noteworthy  that 
in  women  the  symptoms  of  wandering  kidney  are  generally  inten- 
sified at  the  menstrual  period.  I  have  had  under  observation 
women  in  whom  wandering  kidney  could  be  demonstrated  dis- 
tinctly almost  only  at  the  menstrual  period.  The  demonstration 
of  a  wandering  kidney  during  life  is  therefore  of  importance, 
because  the  condition  might  be  readily  overlooked  after  death 
if  the  kidney  has  accidentally  been  restored  to  its  usual  situation 
when  the  body  is  placed  in  the  recumbent  posture. 

Prognosis. — Wandering  kidney  is  a  troublesome  and  fre- 
quently an  incurable  condition,  although,  as  a  rule,  it  is  not  attended 
with  danger  to  life.  Symptoms  of  incarceration  will  only  excep- 
tionally be  followed  by  death  from  uremia.  In  the  prognosis  the 
observation  is  Avorthy  of  consideration  that  a  wandering  kidney 
exhibits  a  tendency  to  carcinomatous  degeneration. 

Treatment. — As  a  prophylactic  measure,  the  wearing  of  tight 
clothing  and  constricting  waistbands  and  belts  should  be  strictly 
forbidden.  Not  much  can  be  accomplished  with  internal  remedies 
in  the  treatment  of  movable  kidney.  Only  in  emaciated  persons 
will  rest  in  bed  and  a  fattening  diet  sometimes  be  followed  by 
replacement  of  a  wandering  kidney  as  soon  as  the  fatty  capsule 
of  the  organ  has  been  sufficiently  developed  and  gives  the  organ 
greater  support.  Naturally,  this  result  can  be  expected  only  in 
cases  that  are  not  too  far  advanced.  Individuals  Avith  wandering 
kidney  should  avoid  bodily  strain  and  secure  an  easy  evacuation 
of  the  bowels  daily.  Women  should  not  lace  their  clothing 
tightly,  but  should  Avear  it  suspended  from  bands  passing  over 
the  shoulders.  The  Avearing  of  an  abdominal  bandage  mav  be 
recommended,  surrounding  the  abdomen  from  the  umbilicus  down- 
Avard,  and  by  pressure  forcing  the  kidney  upAvard  toward  its 
natural  position.  Bandages  Avith  compresses,  designed  directly  to 
force  the  kidney  upward,  rarely  fit  Avell.  Often  the  movable  organ 
slips  from  beneath  the  compress,  and  the  bandage  then  does  more 
harm  than  good.  At  times  wandering  kidney  has  been  relieved 
by  massage.  In  cases  in  which  the  symptoms  are  aggravated 
surgical  treatment  has  been  attempted.  The  most  certain  pro- 
cedure consists  in  removal  of  the  moA^able  kidney — nephrectomy  ; 
but  this  Avill  preferably  not  be  undertaken,  because  it  is  not  rarely 
obserA^ed  that  the  function  of  the  other  kidney  foils,  and  death 
results  from  uremia.  As  a  rule,  it  will  therefore  suffice  to  suture 
the  kidney  in  its   normal  situation — neplirojrhaphy.     Naturally, 


432  GENITO-URINARY  ORGANS 

it  may  happen  tliat  after  some  time  the  kidney  will  again  become 
movable,  and  permanent  relief  is  not  afforded.  Such  complications 
as  may  arise  should  be  treated  according  to  the  usual  rules.  In 
cases  of  incarceration  of  a  wandering  kidney  efforts  should  l)e 
made  to  replace  the  organ,  hot  cataplasms  should  be  applied, 
warm  tea  should  be  drunk,  and,  if  pain  be  considerable,  morphia 
may  be  administered  subcutaneously. 

Dystopia  of  the  kidney  is  the  designation  given  to  an  immovable  displace- 
ment of  the  kidney  which  may  be  eitlier  congenital  or  acquired.  Congenital 
displacement  of  the  kidney  is  generally  left-sided.  At  times  the  organ  is 
found  in  the  true  pelvis.  By  causing  contraction  of  the  pelvis,  obstruction 
to  labor  may  result.  Acquired  displacement  of  the  kidney  may  occur  in 
connection  with  wandering  kidney  if  the  organ  becomes  attached  in  an 
abnormal  situation,  but  sometimes  it  occurs  also  as  the  result  of  pressure 
upon  the  kidney  by  adjacent  organs. 

HORSESHOE  KIDNEY. 

Horseshoe  kidney  results  from  the  coalescence  of  the  two  kid- 
neys into  a  single  organ.  Generally  the  two  lower  poles  of  the 
kidneys  are  united,  so  that  a  semilunar  or  horseshoe-shaped  body 
results,  with  its  concavity  directed  upward.  The  ureters  traverse 
the  anterior  aspect  of  the  body  downward.  The  coalescence  of 
the  kidneys  is  associated  with  their  displacement,  for  generally  the 
two  organs  are  situated  upon  the  anterior  aspect  of  the  lumbar 
vertebra.  Occasionally,  the  kidneys  coalesce  at  the  margins  of 
the  hilus.  In  this  way  there  results  a  disc-shaped  or  cake-shaped 
body,  which  may  possess  a  single  pelvis,  but  giving  off  two  ureters. 
Symptoms  are  usually  absent,  and  often  the  condition  is  discov- 
ered either  accidentally  on  careful  examination  of  the  abdominal 
cavity,  or  possibly  only  upon  post-mortem  examination.  The 
diagnosis  is  by  no  means  easy,  and  other  abdominal  tumors  must, 
in  the  first  place,  be  excluded.  Besides,  it  may  be  found  that  the 
loins  are  depressed,  and  on  percussion  yield  a  tympanitic  note. 

ABSENCE  OF  THE  KIDNEY. 

At  times  one  kidney  may  be  absent,  and  the  knowledge  of  this 
fact  is  naturally  of  the  greatest  importance  in  considering  the 
operation  of  nephrectomy.  The  condition  may  be  congenital  or 
acquired.  Thus,  the  kidney  has  occasionally  been  found  trans- 
formed into  a  mass  of  fat. 

Sitperniimerary  J:idncys  are  without  clinical  significance. 

INFLAMMATION  OF  THE  PARARENAL  CONNEC- 
TIVE TISSUE  (PARANEPHRITIS). 

Ktiology. — Inflammation  of  the  loose  and  partly  fatty  con- 
nective tissue  surrounding  the  kidney  scarcely  occurs  other  than 
as  a  result  of  the  activity  of  bacteria,  and  among  the  exciting 


INFLAMMATION  OF  PARARENAL   CONNECTIVE  TISSUE  433 

agents  thus  far  isolated  are  the  Streptococcus  pyogenes,  Staphylo- 
coccus pyogenes,  Bacterium  coli,  tubercle-bacilli,  pneumonia- 
cocci,  and  actinomyces.  Exposure  to  cold  may  be  a  contributing 
factor  in  the  development  of  infection  of  the  pararenal  connective 
tissue  by  bacteria,  although  the  occurrence  of  a  refrigeratory 
(rheumatic)  paranephritis  can  scarcely  be  accepted  as  demonstrated 
with  certainty.  On  the  other  hand,  traumatic  paranephritis  un- 
doubtedly occurs.  IN^ot  only  gunshot-wounds,  stab-wounds,  and 
open  wounds  generally  may  be  mentioned  in  this  connection ;  but 
falls  and  blows  upon  and  other  injuries  to  the  loin,  and  violent 
concussion  of  the  body,  and  even  heavy  lifting,  may  be  operative. 
At  times  paranephritis  may  follow  antecedent  infectious  disease,  as, 
for  instance,  typhoid  fever  and  septicopyemia.  Most  commonly^ 
paranephritis  arises  by  extension  from  adjacent  inflammation.  It 
often  develops  in  the  sequence  of  pyelonephritis  (particularly  witli 
urinary  calculi),  carcinoma,  tuberculosis,  and  echinococcus  of  the 
kidney,  and  at  times  of  embolism  of  the  kidney.  Paratyphlitis 
also  may  extend  upward,  and  excite  paranephritis.  At  times 
ulcers  in  the  ascending  or  descending  colon  rupture  into  the 
pararenal  connective  tissue,  and  give  rise  to  paranephritis.  In 
addition,  parametritis,  periproctitis,  carcinoma  and  tuberculosis 
of  the  vertebrse,  abscess  of  the  liver  and  of  the  spleen,  duodenitis, 
psoitis,  and  purulent  pleuritis  may  be  mentioned  as  causative  con- 
ditions. Men  suffer  most  frequently  from  paranephritis.  The 
disorder  is  less  common  in  childhood  than  in  adult  life. 

Anatomic  Alterations. — The  principal  alterations  of  para- 
nephritis consist  in  purulent  infiltration  of  the  pararenal  connec- 
tive tissue,  which,  however,  soon  becomes  transformed  into  a  col- 
lection of  pus.  The  latter  generally  does  not  become  encapsulated, 
and  often  the  pus  is  admixed  with  tissue-detritus.  Not  rarely  it 
possesses  putrid  properties.  The  kidney  is  usually  marked  by 
great  mobility.  At  times  paranephritis  is  complicated  by  peri- 
nephritis, and  inflammation,  and  even  accumulation  of  pus,  may 
take  place  within  the  capsule  of  the  kidney.  The  inflammatory 
process  may  also  extend  to  the  tissue  of  the  kidney  itself,  and 
cause  purulent  destruction  of  this  organ.  At  times  inflammation 
and  erosion  of  the  vertebrae  and  purulent  infiltration  and  de- 
struction  of   adjacent   muscular  structures  have  been  observed. 

Symptoms  and  Diagnosis. — The  symptoms  of  paraneph- 
ritis are  in  part  local  and  in  part  general.  Only  rarely  does  para- 
nephritis set  in  like  an  acute  infectious  disease,  with  a  chill  and 
high  fever.  Far  more  commonly  the  disease  begins  insidiously. 
Often,  complaint  is  first  made  of  pain  in  the  loin,  which  is  usually 
increased  upon  pressure.  The  patients  generally  assume  a  con- 
strained attitude,  walking  with  the  upper  portion  of  the  body  bent 
forward  and  toward  the  diseased  side  ;  or  in  bed  they  lie  upon  the 
diseased  side,  holding  the  vertebral  column  convex  toward  the 

28 


434  GENITO-URINARY  ORGANS 

healthy  side,  with  the  lower  extremity  upon  the  diseased  side  flexed 
at  the  hip-joint  and  the  knee-joint.  The  dia<i;nosi.s  cannot  be  made 
with  certainty  until  a  visible  swelling  and  palpable  resistance  have 
made  their  appearance  in  the  loin.  The  increased  resistance  gen- 
erally appears  earliest,  and  becomes  particularly  distinct  upon 
bimanual  palpation  of  the  kidney.  At  first  it  involves  rather  the 
lumbar  region  proper,  but  it  subsequently  extends  gradually 
toward  the  side  and  forward.  A  distinct  limitation  of  the  area 
of  resistance  is  generally  wanting,  and  becomes  apparent  only 
after  the  inflammatory  process  has  existed  for  a  considerable 
period  of  time.  The  side  upon  which  the  diseased  kidney  is  situ- 
ated often  bulges  posteriorly.  The  skin  is  often  edematous  and 
reddened.  Derangement  of  micturition  is  usually  wanting,  and 
the  urine  itself  is  generally  unaltered.  As  a  rule,  irregular  fever 
is  present,  and  chills  may  occur  from  time  to  time. 

A  common  complication  is  pleurisy  (generally  serous)  upon  the 
same  side  of  the  body.  The  course  of  paranephritis  may  extend 
over  from  four  to  six  weeks,  or  even  from  two  to  four  months,  and 
still  longer,  and  a  distinction  accordingly  is  made  between  acute, 
subacute,  and  chronic  paranephritis.  The  disease  may  terminate 
in  complete  recovery  by  absorption  of  the  products  of  the  inflam- 
matory process,  but  more  commonly  rupture  of  the  pus  takes  place 
unless  anticipated  by  surgical  intervention.  Rupture  of  the  pus 
may  take  place  into  the  stomach,  the  intestine,  the  pelvis  of  the 
kidney  and  the  ureter,  the  pleura  and  the  bronchi,  the  abdominal 
cavity,  or  externally.  In  the  last-named  event  extensive  burrow- 
ing often  takes  place.  The  attending  dangers  are  of  variable 
degree.  Rupture  into  the  abdominal  cavity  will  generally  give 
rise  to  rapidly  fatal  peritonitis.  Long-continued  suppuration  is 
attended  witii  danger  of  amyloid  disease  and  fatal  exhaustion. 

Prognosis. — The  prognosis  of  paranephritis  is  not  unfavor- 
able if  the  accumulation  of  pus  be  incised  and  evacuated  at  the 
proper  time. 

Treatment. — As  long  as  fluctuation  cannot  be  elicited  over 
the  area  of  inflammation  an  attempt  should  be  made  to  restrain 
the  progress  of  the  inflammatory  process  by  tlie  application  of  an 
ice-bag  to  the  loin,  or  to  stimulate  absorption  of  inflammatory 
products  by  the  application  of  hot  cataplasms.  As  soon  as  fluctu- 
ation can  be  elicited  there  is  but  one  remedy,  namely,  incision. 
Further,  it  may  be  exceedingly  difficult  to  appreciate  deep-seated 
fluctuation,  so  that  resort  has  been  liad  to  exploratory  puncture. 

ANEURYSM  OF  THE  RENAL  ARTERY. 

Aneurysm  of  the  renal  artery  is  a  rare  condition.  It  is  often 
unrecognized  during  life.  The  patient  dies  suddenly  from  inter- 
nal hemorrhage,  the  source  of  which  is  discovered  upon  post-mor- 


DILATATION  OF  THE  PELVIS   OF  THE  KIDNEY        435 

tem  examination  to  be  a  ruptured  aneurysm  of  the  renal  artery. 
Only  rarely  will  a  tumor'  with  expomsUe  pulsation  be  palpable  in  the 
renal  region.  More  commonly  symptoms  of  rerial  colic  and  hema- 
turia are  present,  so  that  the  clinical  picture  is  suggestive  of  renal 
calculus. 

Treatment  is  ineffective. 


II.   DISEASES  OF  THE  PELVIS  OF  THE  KIDNEY 
AND   OF  THE   URETER. 


DILATATION   OF   THE   PELVIS   OF   THE  KIDNEY 
(HYDRONEPHROSIS) , 

i^tiology. — Dilatation  of  the  pelvis  of  the  kidney  is  inva- 
riably the  result  of  urinary  stasis.  In  accordance  with  the  seat 
of  the  causes  of  the  stasis  hydronephrosis  may  be  unilateral  or 
bilateral,  the  latter  particularly  if  the  causes  are  related  to  disease 
of  the  bladder  or  the  urethra.  A  common  cause  for  hydronephro- 
sis is  constituted  by  renal  calculi,  which  have  formed  in  the  pelvis 
of  the  kidney  and  have  found  their  way  into  and  obstructed  the 
ureter.  A  similar  result  may  be  brought  about  by  echinococci, 
carcinoma,  and  tuberculosis  of  the  kidneys  and  of  the  pelvis  of  the 
kidney,  if  echinococcus-vesicles,  carcinomatous  tissue,  or  cheesy 
masses  have  become  detached  and  are  impacted  in  the  ureter. 
Also,  in  cases  of  pyelitis  and  hemorrhage  into  the  pelvis  of  the  kid- 
ney, blood-clots  or  plugs  of  pus  not  rarely  cause  obstruction  of  the 
ureter  and  give  rise  to  hydronephrosis.  Obstruction  is  but  rarely 
due  to  parasites.  Among  the  diseases  of  the  bladder,  paralysis  and 
tumors  particularly  may  be  mentioned  as  causes  of  hydronephro- 
sis. Of  diseases  of  the  urethra,  all  varieties  of  constriction  and 
obstruction  must  be  taken  into  consideration.  An  associated 
group  of  causes  includes  the  compression-stenoses  of  the  urinary 
passages,  which  not  rarely  give  rise  to  hydronephrosis.  Among 
the  more  common  of  these  conditions  peritoneal  exudates,  dis- 
placements and  neoplasms  of  the  uterus,  ovarian  tumors,  carci- 
noma of  the  rectum,  and  prostatic  hypertrophy  may  be  mentioned. 
Hydronephrosis  resulting  from  torsion  or  kinking  of  the  ureter  has 
already  been  considered  in  the  discussion  of  the  symptoms  attend- 
ing incarceration  of  a  wandering  kidney  (p.  430).  Hydronephro- 
sis may  further  be  of  congenital  origin.  The  causes  of  this  char- 
acter consist  at  times  in  abnormal  valvular  formations  at  the 
junction  of  the  ureter  Avith  the  pelvis  of  the  kidney  or  with  the 
bladder,  and  at  other  times  in  unusual  length  of  the  course  of  the 
ureter  within  the  wall  of  the  bladder.     Also,  congenital  atresia  of 


436  GENITO-URINARY  ORGANS 

the  ureter,  the  bladder,  or  the  urethra  shouhl  be  mentioned  in 
this  connection. 

Anatomic  Alterations. — The  most  important  anatomic 
alteration  attending  hydronephrosis  is  naturally  the  dilatation 
of  the  pelvis  of  the  kidney,  and  which  may  attain  such  a  marked 
degree  as  to  equal  or  even  exceed  the  size  of  an  adult  head. 
When  the  pelvis  of  the  kidney  becomes  so  greatly  enlarged  the 
related  kidney  itself  must  naturally  be  involved.  The  latter 
becomes  compressed,  flattened,  and  stretched,  and  at  times  consists 
only  of  a  thin  band  of  renal  tissue.  The  ureter  itself  may  also 
participate  in  the  dilatation,  and  at  times  attains  the  size  of  a 
loop  of  small  intestine,  and,  like  this,  it  may  form  several  con- 
volutions. 

At  times,  in  the  presence  of  abnormal  valvular  formations  in  the  pelvis 
of  the  kidney,  hydronephrosis  may  be  confined  to  one  or  more  renal  calices 
— -partial  hydronephrosis — and  it  will  be  recognizable  from  the  flattening  and 
compression  of  the  corresponding  renal  papillje. 

The  contents  of  the  dilated  renal  pelvis  consist  of  stagnant 
urine,  which  is  either  unchanged  or,  in  consequence  of  inflamma- 
tion of  the  pelvis  of  the  kidney,  has  acquired  a  purulent,  at  times 
a  gelatinous,  or,  as  a  result  of  admixture  of  blood,  a  reddish, 
reddish-brown,  almost  chocolate-like  appearance.  If  complete 
obstruction  of  the  ureter  has  existed  for  a  considerable  length  of 
time,  urea  and  uric  acid  may  disappear  from  the  fluid.  In  some 
cases  obstruction  to  the  flow  of  urine  can  scarcely  be  demon- 
strated with  certainty,  as  reflections  and  valvular  formations  readily 
become  obliterated  in  the  dead  body,  and  may  perhaps  be  apparent 
only  under  certain  conditions  of  distention  and  in  certain  posi- 
tions. 

Symptoms. — It  is  useful  to  separate  the  symptoms  of  con- 
genital from  those  of  acquired  hydronephrosis.  Congenital  hydro- 
nephrosis mav  at  times  attain  such  considerable  proportions  as  to 
constitute  an  obstruction  to  labor,  and  which  can  be  overcome  only 
by  puncture  or  even  by  embryotomy.  If  a  child  with  congenital 
hydronephrosis  is  born  alive,  it  will  exhibit  frequently  dyspnea 
and  cvanosis,  because  the  diaphragm,  the  lungs,  and  the  heart  are 
displaced  upward,  and  death  may  result  within  a  short  time  in 
consequence  of  asphyxia  or  cardiac  paralysis.  Death  may  result 
also  from  uremia.  Not  rarely  the  little  patient  presents  also 
other  malformations,  as,  for  instance,  harelip,  cleft  palate,  club- 
foot. At  times  congenital  hydronephrosis,  which  further  is  often 
bilateral,  is  observed  in  several  children  in  the  same  family. 

Acquired  ht/dronephrosis  is  recognized  during  life  only  when  a 
tumor  in  the  loin  can  be  demonstrated  which  while  luider  observa- 
tion graduallv  increases  in  size,  while  at  the  same  time  stasis-pro- 
ducing conditions  are  present  in  the  urinary  passages.  Frequently, 
but  by  no  means  constantly,  fluctuation  can  be  elicited  over  the 


DILATATION  OF  THE  PELVIS  OF  THE  KIDNEY        437 

renal  tumor.  Of  especial  importance  in  the  diagnosis  is  palpation 
of  the  dilated  ureter,  but  this  is  rarely  possible.  At  times  the 
patients  complain  of  pain  in  the  renal  region,  and  tenderness  on 
pressure  may  be  present  in  the  same  situation.  The  more  rapidly 
hydronephrosis  develops  and  the  more  extensive  it  becomes,  the 
more  intense  is  the  renal  pain  likely  to  be.  The  changes  in  the 
amount  and  the  constitution  of  the  urine  are  noteworthy,  for  if 
large  amounts  of  urine  collect  in  the  pelvis  of  the  kidney  within  a 
short  time,  the  amount  of  urine  excreted  will  appreciably  diminish. 
Naturally,  the  sudden  disappearance  of  hydronephrosis  will  be 
revealed  by  rapid  increase  in  the  amount  of  urine.  When  the 
urine  is  rendered  turbid  by  admixture  with  pus,  it  becomes  clear 
when  the  ureter  of  the  inflamed  renal  pelvis  is  obstructed,  and  the 
entrance  of  purulent  urine  into  the  bladder  is  prevented,  with 
simultaneous  development  of  hydronephrosis.  Under  such  condi- 
tions, with  the  removal  of  the  obstruction,  disappearance  of  the 
hydronephrosis,  and  increase  in  the  amount  of  urine,  the  urine 
again  becomes  turbid.  Not  rarely,  in  consequence  of  urinary 
stasis,  uremic  and  urinary  septic  symptoms  appear,  particularly 
chills,  febrile  movement,  nausea,  vomiting,  headache,  even  convul- 
sive attacks.  These  symptoms  are  observed  with  particular  fre- 
quency when  hydronephrosis  is  bilateral,  and  then  death  may  ensue 
from  uremia. 

The  duration  of  hydronephrosis  depends  upon  the  causative 
factors  in  the  individual  case.  At  times  the  condition  persists  for 
a  few  hours  or  days — acute  hydronephrosis;  at  other  times  for 
years,  or  throughout  life — chronic  hydi'onephrosis.  In  accordance 
with  the  course  of  the  disease,  several  varieties  of  hydronephrosis 
have  been  distinguished.  The  designation  intermittent  hydroneph- 
rosis has  been  applied  to  cases  in  which  the  factors  causative  of 
urinary  stasis  are  frequently  repeated,  and  each  time  give  rise  to 
hydronephrosis,  which  disappears  with  the  removal  of  the  ob- 
struction. The  designation  remittent  hydronephrosis  is  applied  to 
cases  in  which  the  condition  persists  continuously,  and  from  time 
to  time  undergoes  increase  and  then  diminution.  A  reduction  in 
the  hydronephrosis  takes  place  Avhen  the  urine  in  the  dilated  renal 
pelvis  becomes  subjected  to  such  a  considerable  degree  of  pressure 
that  this  is  capable  of  partially  overcoming  the  obstruction  and 
permitting  partial  evacuation  of  the  renal  pelvis.  Accordingly  as 
the  flow  of  urine  from  the  pelvis  of  the  kidney  is  completely  or 
partially  interfered  with,  a  distinction  is  made  between  open  and 
closed  hydronephrosis.  In  addition  to  the  dangers  of  uremia  and 
septicemia  already  mentioned,  there  is,  besides,  a  possibility  of 
rupture  of  the  dilated,  renal  pelvis,  but  this  occurrence  is  rare. 

Diagnosis  and  Prognosis. — The  recognition  of  hydro- 
nephrosis is  not  easy  even  when  a  renal  tumor  is  demonstrable. 
In  the  diagnosis  the  demonstration  of  conditions  capable  of  causing 


438  GENITO-URINARY  ORGANS 

urinary  stasis  is  decisive.  It  is  therefore  necessary  in  every  case 
to  endeavor  to  determine  these,  because  the  prognosis  and  the 
treatment  will  be  governed  accordingly. 

Treatment. — The  treatment  of  hydronephrosis  can  be  only 
mechanical.  Efforts  sliould  be  made  to  remove  the  causes  of  the 
urinary  stasis.  Should  life  be  threatened  in  consequence  of  the 
extent  of  the  hydronephrosis  or  of  suppuration,  nephrotomy  or 
nephrectomy  will  have  to  be  decided  upon,  in  accordance  with  the 
condition  of  the  related  kidney.  Furtiier,  nephrectomy  is  not 
rarely  complicated  by  serious  difficulties  from  the  fact  that  the 
dilated  renal  pelvis  is  often  intimately  adherent  to  the  stomach 
or  to  adjacent  loops  of  intestine. 


INFLAMMATION  OF  THE  PELVIS  OF  THE  KIDNEY 

(PYELITIS). 

Ktiolog"y. — Pyelitis  results  from  either  bacterial  or  toxic 
influences,  most  commonly  from  the  former.  The  exciting  agents 
of  the  inflammatory  process  include  the  same  bacteria  that  have 
been  mentioned  as  the  causes  of  suppurative  nephritis,  and  this 
fact  is  readily  explained  from  the  circumstance  that  pyelitis  and 
nephritis  are  frequently  associated — so-called  pyelonephritis.  Ac- 
cordingly, in  addition  to  the  ordinary  pyogenic  microorganisms 
(Streptococcus  pyogenes,  Staphylococcus  pyogenes),  the  Bacterium 
coli  particularly,  and,  further,  also  pneumoniacocci,  tubercle- 
bacilli,  and  typhoid-bacilli  must  be  mentioned.  Frequently 
bacteria  gain  entrance  from  the  bladder  into  the  ureter  and 
the  pelvis  of  the  kidney,  and  pyelitis  thus  readily  becomes  asso- 
ciated with  inflammatory  disorders  of  the  urinary  bladder  and 
the  urethra.  The  danger  is  particularly  great  when  urinary  stasis 
results.  At  other  times  pyelitis  is  the  result  of  disease  of  the 
renal  pelvis  itself.  It  occurs  Avith  especial  constancy  in  connec- 
tion with  renal  calculi  and  with  tuberculosis,  carcinoma,  and 
parasites  of  the  renal  pelvis.  Little  of  a  definite  nature  is  known 
with  regard  to  refrigeratory  (rheumatic)  ]")yelitis,  while,  on  the 
contrary,  traumatic  pyelitis  may  undoubtedly  occur  after  a  fall, 
blow,  or  injury  in  the  renal  region.  The  traumatism,  however, 
has  only  the  significance  of  a  contributory  cause  for  the  infection 
of  the  pelvis  of  the  kidney  with  bacteria.  Pyelitis  is  often  asso- 
ciated with  diseases  of  the  kidney.  It  is  a  frequent  phenomenon 
in  the  presence  of  hypostasis  of  the  kidney,  acute  diffuse  neph- 
ritis, and  the  remaining  forms  of  diffuse  nephritis,  sup])urative 
nephritis,  carcinoma,  tuberculosis,  and  echinococcus  of  the  kidney, 
etc.  At  times  pyelitis  arises  by  extension  from  adjacent  disease, 
and  it  may  complicate  paranephritis  and  peritonitis.  In  some  cases 
pyelitis  develops  in  the  sequence  of  infectious  diseases,  as,  for 


INFLAMMATION  OF  THE  PELVIS  OF  THE  KIDNEY    439 

instance,  small-pox,  typhoid  fever,  pneumonia,  erysipelas,  scarlet 
fever,  etc.  Toxic  pyelitis  may  develop  after  the  ingestion  and 
the  employment  of  all  those  remedies  that  have  been  mentioned 
on  pp.  402  and  403  as  causes  of  acute  nephritis,  and  among  which 
particularly  mineral  acids,  carbolic  acid,  balsamics,  and  cantharides 
may  be  mentioned  here.     Pyelitis  is  rare  in  children. 

Anatomic  Alterations. — Inflammation  of  the  mucous  mem- 
brane of  the  pelvis  of  the  kidney  is  attended  with  hyperemia, 
swelling,  and  increased  secretion  of  the  mucous  membrane.  Here 
and  there  also  small  extravasations  of  blood  have  taken  place 
into  the  mucous  membrane.  So  long  as  the  condition  is  one  only 
of  increased  secretion  of  mucus  and  possibly  excessive  desqua- 
mation of  the  epithelium  of  the  mucous  membrane  it  can  be 
designated  a  mucous  or  desquamative  catarrh  of  the  renal  pelvis. 
In  some  cases,  however,  there  is  active  formation  of  pus,  so  that 
the  condition  becomes  one  of  purulent  pyelitis.  Considerable 
hemorrhage  from  the  surface  of  the  mucous  membrane  gives  rise 
to  the  clinical  picture  of  hemorrhagic  pyelitis.  Toxic  causative 
factors  may  give  rise  to  a  fibrinous  pyelitis.  A  necrotizing  pye- 
litis develops  when  the  mucous  membrane  of  the  renal  pelvis 
throughout  a  greater  or  lesser  extent  is  converted  into  a  necrotic, 
friable  grayish-green  or  blackish  tissue.  Secondary  involvement 
of  the  kidneys  in  the  inflammatory  process  is  readily  possible 
from  the  fact  that  bacteria  may  gain  entrance  to  the  uriniferous 
tubules  directly  from  the  renal  pelvis,  and  from  this  point  may 
excite  inflammation.  Generally  the  ureters  also  are  involved  in 
the  inflammatory  process.  Pyelitis  may  be  unilateral  or  bilateral, 
accordingly  as  the  causative  factors  are  operative  upon  one  side 
or  upon  both,  being  unilateral,  for  instance,  in  the  presence  of 
renal  calculi,  parasites,  and  paranephritis. 

Symptoms  and  Diagnosis. — A  positive  diagnosis  of  pye- 
litis is  often  impossible,  and  in  the  majority  of  cases  more  than 
a  tentative  diagnosis,  upon  an  empirical  basis,  cannot  be  made. 
If  pyelitis  is  associated  with  disease  of  the  kidneys,  bladder,  or 
urethra,  the  urinary  alterations  of  the  former  condition  are  often 
obscured  by  those  of  the  renal,  vesical,  or  urethral  disorder.  In 
cases  of  pyelitis  of  rather  independent  origin  attention  should  be 
directed  particularly  to  local  alterations  in  the  kidneys  and  to 
changes  in  the  urine.  Patients  with  pyelitis  often  complain  of 
a  sense  of  tension,  of  pressure,  and  even  of  pain  in  the  renal  region, 
which,  when  the  pyelitis  is  unilateral,  may  be  referred  only  to  the 
corresponding  side.  Pressure  in  the  renal  region  is  likely  to 
increase  the  pain,  or  may  induce  it.  The  changes  in  the  urine 
vary  with  the  nature  of  the  inflammatory  process.  In  the  mild- 
est cases  the  urine  contains  only  an  increased  amount  of  mucus, 
so  that  the  cloudiness  of  normal  urine  is  increased  in  amount 
and  density.     On  microscopic  examination  of  the  urinary  sedi- 


440  GENITO-URINARY  ORGANS 

ment  attention  may  be  attracted  at  times  by  caudate  or  club- 
shaped  epithelial  cells,  which  may  be  derived  from  the  deeper 
epithelial  layers  of  the  urinary  bladder,  but  which  are  rather 
suggestive  of  pyelitis  when  large  squamous  epithelial  cells  are 
wanting  in  the  urinary  sediment,  and  when  the  cells  present  are 
abundant  and  arranged  in  layers  like  shingles  on  a  roof.  In 
cases  of  purulent  pyelitis  the  urinary  sediment  usually  contains 
polynuclear  pus-corpuscles.  As  long  as  the  kidney  is  not  involved 
in  the  inflammatory  process  the  filtered  urine  will  contain  no 
albumin,  or  only  traces  thereof.  Also,  no  tube-casts  are  found  in 
the  sediment.  Similar  alterations  in  the  urine  attend  cystitis  and 
urethritis,  but  the  pain  in  the  renal  region  is  often  distinctive  of 
pyelitis.  In  cases  of  hemorrhagic  pyelitis  hematuria  occurs,  and 
the  urine  may  contain  cylindric  coagula  that  have  formed  in  the 
ureter.  Pyelitis  is  often  associated  with  hydronephrosis,  because 
the  ureter  is  obstructed  by  collections  of  pus-corpuscles  or  blood- 
clots.  Under  such  conditions  severe  renal  pain  occurs  suddenly, 
with  chill,  fever,  vomiting,  and  diminution  in  the  amount  of 
urine,  which  becomes  clear ;  these  symptoms  soon  subside  when 
the  urinary  obstruction  is  relieved. 

In  accordance  with  the  causative  factors  pyelitis  may  pursue 
an  acute,  a  subacute,  or  a  chronic  course.  Chronic  pyelitis  is  gen- 
erally purulent  in  character,  is  associated  as  a  rule  with  purulent 
nephritis,  and  not  rarely  causes  death  by  uremia,  urinary  septice- 
mia, rupture  into  the  neighborhood,  or  amyloid  disease. 

Prognosis. — The  prognosis  of  pyelitis  depends  upon  the 
curability  of  the  causative  conditions. 

Treatment. — Every  case  of  pyelitis  requires,  in  the  first  place, 
causal  therapy.  Under  all  conditions  the  patient  should  be  kept 
in  "bed,  in  order  to  maintain  a  uniform  temperature,  and  be  given 
fluid  to  drink  in  abundance,  in  order  to  dilute  the  urine  as  largely 
as  possible  and  to  avert  urinary  stasis  in  the  ureter.  For  this 
purpose  well-boiled  milk,  to  which  lime-water  (1  tablespoonful  to 
each  glass  of  milk)  is  added,  red  wine  diluted  half  with  M^ater, 
and  tea,  particularly  an  infusion  of  uva  ursi  leaves  (1  tablespoon- 
ful to  a  large  cupful  of  hot  water  three  or  four  times  daily),  may  be 
particularly  recommended.  If  thirst  be  marked,  alkaline  waters 
may  be  prescribed  (Wildungen,  Fachingen,  Ems,  Vichy),  or  carbon- 
ated waters  (Bilin,  Giesshubel).  For  the  relief  of  pain  in  the  renal 
region  hot  cataplasms  may  be  applied.  Internally  disinfectants, 
■balsamics,  or  astringents  may  be  administered.  Personally  I  usu- 
ally begin  with  salol,  and  after  from  ten  to  fourteen  days  substitute 
oil  of  turpentine,  and  finally  prescribe  tannic  acid  : 

R   Salol,  1.0  (15  grains)  ; 

Saccharin,  0.02  (^  grain).— M. 

Make  10  such  powders. 
Dose:  1  powder  every  two  hours. 


RENAL  CALCULI  441 

B   Oil  of  turpentine,  10.0  (2^  fluidrams). 

Dose :  10  drops  in  milk  thrice  daily. 

R   Tannic  acid,  0.3  (42  grains) ; 

Saccharin,  0.02  (^  grain). — M. 
Make  10  such  starch-capsules. 
Dose :  1  capsule  every  three  hours. 

Profound  involvement  of  the  kidneys  in  the  inflammatory  process 
may  require  nephrotomy  or  nephrectomy,  as  has  been  mentioned 
on  p.  420. 

RENAL  CALCULI    (NEPHROLITHIASIS), 

Anatomic  Alterations. — The  pelvis  of  the  kidney  is  a  fre- 
quent seat  for  the  deposition  of  earthy  precipitates  from  the  urine. 
In  accordance  with  their  size  a  distinction  has  been  made  between 
renal  sand  and  i-enal  calculi,  the  latter  designation  being  applied 
only  to  grains  of  precipitate  larger  than  a  pin-head  in  size. 
Chemically,  calculi  may  consist  of  urates,  phosphates,  oxalates, 
carbonates,  xanthin,  cystin,  or  indigo. 

In  some  instances  fibrinous  concretions  have  been  encountered  in  the 
pelvis  of  the  kidney.  These  have  resulted  from  antecedent  hemorrhage, 
and  consist  of  tough,  flexible,  and  extensile  structures  that  are  inflammable 
and  yield  the  odor  of  burning  feathers. 

Uratio  calculi  consist  of  uric  acid,  or  generally  of  its  salts 
(urates).  They  are  the  most  common  variety  of  renal  calculi, 
are  generally  hard,  and  sometimes  possess  a  smooth  and  at  other 
times  a  granular  surface.  In  color  they  vary  from  brown  to 
yellow.  Upon  transverse  section  dark  and  light  layers  often 
alternate  with  each  other..  Occasionally  the  nucleus  consists  of 
oalcium  oxalate.  The  cortex  at  times  is  formed  of  earthy  phos- 
phates. Uric  acid  and  urates  can  be  readily  recognized  by  means 
of  the  murexid-test. 

Phosphatic  calculi  consist  of  calcium  phosphate  and  amraonio- 
magnesium  phosphate  (triple  phosphate),  and  but  rarely  of  the 
latter  alone.  That  phosphatic  deposits  are  occasionally  present 
in  the  cortex  of  uratic  calculi  has  already  been  mentioned. 
Phosphatic  calculi  are  friable,  at  times  smooth,  at  other  times 
nodular,  and  they  vary  in  color  between  gray,  yellowish  red,  and 
reddish  violet. 

Oxalate-calculi  consist  of  calcium  oxalate,  and  are  generally 
characterized  by  a  multinodular  surface,  so  that  they  have  also 
been  designated  midberry-calcidi.  In  color  they  are  frequently 
deep  black,  because  their  sharp  prominences  give  rise  to  consider- 
able hemorrhao;e.     Their  decree  of  hardness  is  considerable. 

Carbonate-calculi  are  but  rarely  found  in  human  beings.  They 
possess  a  whitish  or  a  reddish  color,  and  are  readily  recognized  from 
the  fact  that  the  calcium  carbonate  is  dissolved  in  hydrochloric 
acid  with  effervescence  and  the  generation  of  carbon  dioxid. 


442  GENITO-URINARY  ORGANS 

Xanthin-calculi  likewise  are  rare.  They  vary  in  color  from 
yellowish  brown  to  dark  brown,  and  the  fractured  surface,  when 
rubbed,  yields  a  waxy  luster. 

Cystin-calcull  are  hereditary  in  some  families,  and  are  among 
the  less  common  varieties.  They  vary  in  color  between  white, 
yellow,  and  dark  gray,  although  they  may  be  green  or  blue. 
Their  surface  is  at  times  smooth,  at  other  times  rough.  Occasion- 
ally the  nucleus  consists  of  uric  acid,  and  the  cortex  of  earthy 
phosphates.  Scrapings  from  the  calculus  are  soluble  in  i)otassium 
hydroxid  and  ammonia,  and  on  evaporation  six-sided  plates  of 
cystin  crystallize  out. 

Indif/o-calculi  occur  but  rarely.  They  are  conspicuous  for 
their  bluish-black  color,  and  for  staining  paper  over  which  they 
are  drawn. 

The  size,  the  number,  and  the  shape  of  renal  calculi  exhibit  re- 
markable variations.  In  general  the  size  of  renal  calculi  will 
be  the  greater  the  smaller  their  number  and  the  greater  room  for 
growth  they  have.  Renal  calculi  as  large  as  a  hen's  egg  have  been 
observed.  In  general,  the  roundish  or  cylindric  shape  preponder- 
ates. At  times  a  single  calculus  almost  wholly  occupies  the  en- 
tire pelvis  of  the  kidney,  and  some  of  the  processes  may  extend 
into  the  calices  of  the  kidney,  so  that  shapes  result  that  have  been 
appropriately  compared  with  the  appearance  of  the  antlers  of  a 
deer.  At  times  renal  calculi  develop  within  the  calyx  of  a  kid- 
ney, and  in  consequence  acquire  a  shape  suggestive  of  the  appear- 
ance of  a  fumigating  pastil.  In  some  cases  the  pelvis  of  the  kidney 
represents  a  sac  filled  with  numerous  small  calculi,  which  mav 
reach  into  hundreds.  In  association  with  renal  calculi  there 
is  generally  inflammation  of  the  renal  pelvis,  which  it  is  custom- 
ary to  designate  as  calculous  pyelitis.  As  a  rule,  the  inflamma- 
tion is  chronic  in  character,  and  generally  purulent  in  nature.  At 
times  necrosis  and  ulceration  of  the. mucous  membrane  of  the 
renal  pelvis  occur.  The  ulcers  may  perforate  into  adjacent  organs, 
into  the  abdominal  cavity,  or  externally,  and  give  rise  to  the  for- 
mation of,  a  renal-pelvic  fistula.  Renal  calculi  are,  further,  not 
without  influence  upon  the  hirlney  itself.  At  times  contracted  kid- 
ney may  develop,  M'hile  in  other  instances  purulent  inflammation 
of  the  pelvis  of  the  kidney  may  extend  to  the  renal  tissue  and 
give  rise  to  purulent  ncpliritis.  Decomposition  of  the  urine 
within  tlie  pelvis  of  the  kidney  may  readily  cause  involvement  of 
the  ureter  and  the  bladder,  with  the  development  of  chronic  in- 
flammation. In  addition,  these  structures  may  suffer  when  a  renal 
calculus  is  expelled  from  the  pelvis  of  the  kidney  and  attempts  to 
make  its  way  downward. 

^Etiology. — Renal  calculi  are  particulai'ly  common  in  child- 
hood, and  in  .advanced  life.  They  have  even  been  observed  in 
some  instances  in  the  newborn.     Experience  has  shown  that  renal 


RENAL  CALCULI  443 

calculi  are  much  more  common  in  males  than  in  females.  A 
sedentary  mode  of  life  favors  the  formation  of  renal  calculi  in  some 
inexplicable  manner.  The  condition  is  almost  unknown  in  sailors 
and  soldiers.  Renal  calculi  occur  much  more  commonly  in  some 
regions  than  in  others.  England  and  Holland  are  well  known  as 
favorable  soils  for  the  formation  of  renal  calculi.  It  is  a  remark- 
able fact  that  regions  in  which  renal  calculi  are  common  may  ad- 
join without  sharp  limitation  regions  in  which  renal  calculi  do  not 
occur.  In  what  the  geographic  influence  consists  is  as  yet  wholly 
unknown.  Without  doubt,  the  food  has  an  influence  upon  the  for- 
mation of  renal  calculi,  as  persons  are  known  who  invariably  pre- 
sent signs  of  renal  calculi  within  a  short  time  after  taking  a  small 
amount  of  white  wine.  Not  without  reason  the  excessive  use  of 
meat  and  alcohol  is  held  to  favor  the  development  of  renal  calculi. 
At  times  the  formation  of  renal  calculi  is  dependent  upon  dis- 
orders of  metabolism.  Gouty  patients  are  not  rarely  the  victims 
of  renal  calculi.  Individuals  suffering  from  cystinuria  not  rarely 
have  cystin-calculi.  Cystinuria  and  cystin-calculi  are  hereditary 
in  some  families,  and  thus  it  will  be  seen  that  an  inheritance  of 
anomalies  in  metabolism  may  give  rise  to  an  inheritance  of  renal 
calculi.  At  times  renal  calculi  form  about  foreign  bodies  (blood- 
clot,  ova  of  parasites).  They  may  therefore  follow  injuries  in  the 
renal  region  if  hemorrhage  into  the  renal  pelvis  has  taken  place. 
The  formation  of  renal  calculi  is  favored  in  marked  degree  by  all 
inflammatory  diseases  of  the  urinary  passages,  particularly  if  these 
are  attended  with  urinary  stasis  and  decomposition. 

Little  is  definitely  known  with  regard  to  the  intimate  processes  concerned 
in  the  formation  of  renal  calculi.  The  precipitation  of  concretions  from  the 
urine  is  theoretically  possible  under  two  conditions,  namely,  either  if  the 
urine  contains  so  much  of  any  material  that  it  cannot  retain  all  of  it  in 
solution,  or  if  the  reaction  of  the  urine  becomes  so  altered  that  certain  sub- 
stances are  thrown  out  of  solution.  The  simple  precipitation  from  the 
urine  of  substances  capable  of  forming  calculi  by  no  means,  however,  alone 
gives  rise  to  the  formation  of  renal  calculi,  for  microscopic,  and  particularly 
microcheraic,  examination  of  renal  calculi  has  shown  that  the  calculus- 
forming  substances  have  not  simply  crystallized  together,  but  that  they 
are  bound  together  by  an  organic' framework.  This  latter  probably  is 
scarcely  other  than  the  product  of  a  catarrhal  state  of  the  mucous  mem- 
brane of  the  renal  pelvis,  so  that  some  clinicians  have  referred  directly  to  a 
calculus-generating  catarrh.  As,  however,  bacteria  may  play  a  causative 
role  in  the  development  of  such  a  catarrh,  one  is  forced  to  the  conclusion 
that,  as  in  the  development  of  gall-stones,  so  also  in  the  formation  of  renal 
calculi,  bacteria  are  of  great  importance.  In  the  case  of  calculus-formation 
in  decomposed  urine  bacteria  again  are  concerned,  and  they  must  be  looked 
upon  as  the  cause  of  the  alkaline  decomposition.  In  this  way  is  explained 
the  great  influence  that  all  conditions  of  urinary  stasis  exert  upon  the  for- 
mation of  renal  calculi,  for  whenever  urinary  stasis  exists  excessive  devel- 
opment of  bacteria  in  the  urine  is  possible. 

Symptoms  and  Diagnosis. — Renal  calculi  and  renal  sand 
may  be  present  in  the  pelvis  of  the  kidney  without  giving  rise  to 


444  GENITO-URINARY  ORGANS 

any  symptom,  and  they  may  be  found  quite  accidentally  upon 
post-mortem  examination — latent  reiKil  calculi.  In  other  instances 
symptoms  of  pyelitis  or  pyelonephritis  appear,  and  that  these  are 
dependent  upon  renal  calculi  may  be  first  discovered  upon  opera- 
tive intervention  or  after  rupture  externally  with  the  discharge 
of  renal  calculi.  The  circumstance  would  naturally  be  suspicious 
if  the  urine  contained  considerable  crystalline  sediment,  and  from 
the  character  of  this  it  might  be  possible  to  judge  of  the  chemic 
constitution  of  the  calculus.  Xot  rarely  pain  in  the  renal  region  is 
present,  and  this  may  radiate  for  quite  a  distance,  and  not  at  all 
rarely  it  is  for  a  long  time  mistaken  for  lumbago,  intercostal  neu- 
ralgia, or  the  like.  Renal  calculi  at  times  give  rise  also  to  a 
peculiar  constrained  posture  of  the  body.  The  patients  walk  with 
the  body  bent  forward,  with  the  shoulder  depressed  toward  the 
affected  side,  and  the  vertebral  column  convex  toward  the  healthy 
side,  avoiding  from  fear  all  rotatory  and  flexor  movements  of  the 
vertebral  column,  and  they  walk  as  stiffly  as  a  stick,  placing  the  feet 
with  care  gently  upon  the  floor,  Avith  especial  concern  for  the  foot 
upon  the  diseased  side.  At  times  the  patients  complain  for  weeks 
and  months  of  nausea  and  vomiting  before  it  becomes  certain  that 
these  symptoms  are  due  to  reflex  irritation  by  calculi  in  the  pelvis 
of  the  kidney.  The  presence  of  renal  calculi  may  be  concealed 
also  behind  the  clinical  picture  of  chronic  catarrh  of  the  urinary 
bladder. 

Some  patients  suffer  repeatedly  from  hematuria,  as  the  cause 
of  which  renal  calculi  may  be  suggested  from  the  presence 
of  considerable  crystalline  sediment  in  the  urine.  One  of  the 
most  common  morbid  manifestations  is  renal  colic.  This  occurs, 
however,  only  when  calculi  leave  the  pelvis  of  the  kidney  in  an 
effort  to  pass  through  the  ureter  into  the  bladder,  and  remain  im- 
pacted in  the  ureter.  The  patients  then  complain,  in  general 
suddenly,  of  intense  pain  in  one  renal  region,  setting  in  either 
without  appreciable  cause  or  induced  by  bodily  over-exertion  or 
concussion,  emotional  disturbance,  indiscretion  in  eating  and 
drinking,  or  the  like.  The  pain  not  rarely  radiates  to  remote 
parts,  particularly  toward  the  bladder,  and  even  to  the  glans  penis 
and  the  thigh.  The  character  of  the  pain  is  variously  described, 
and  is  almost  uniformly  designated  by  all  patients  as  overwhelm- 
ing. The  facial  expression  is,  therefore,  one  of  fear  and  pain,  and 
the  skin  in  consequence  of  reflex  vascular  spasm  is  pale  and  cool, 
and  frequently  covered  with  cold  and  clammy  sweat.  If  the 
cerebral  vessels  are  involved  in  the  spasm  of  the  vascular  muscles, 
syncope  and  clonic  muscular  spasm  may  result.  Often  chill,  fever, 
and  vomiting  occur. 

Particularly  noteworthy  further  are  changes  in  the  urine  at 
the  time  of  the  attack  of  colic.  As  a  rule,  the  urine  is  passed 
in  diminished  amount,  and  in  some  cases  anuria  occurs,  although 


RENAL   CALCULI  445 

but  one  ureter  is  occluded,  because  the  function  of  the  healthy 
kidney  is  suppressed  in  consequence  of  reflex  irritation.  Should 
the  anuria  persist  for  several  days,  danger  of  uremia  may  arise, 
with  the  possibility  of  a  fatal  termination.  Frequently  the  urine 
is  bloody — hematuria  ;  this  occasionally  persists  for  a  considerable 
time,  and  may  be  quite  abundant.  It  is  due  to  injury  of  the 
mucous  membi-ane  of  the  renal  pelvis  by  the  impacted  calculus. 
If  the  lumen  of  the  ureter  again  becomes  free,  from  either  the 
return  of  the  calculus  into  the  pelvis  or  its  entrance  into  the 
bladder,  the  renal  pain  ceases,  the  urine  again  becomes  abundant, 
and  gradually  the  blood  disappears.  Naturally,  severe  pain  in 
the  bladder  and  urethra  may  be  renewed  when  the  calculus  begins 
its  passage  from  the  bladder  through  the  urethra  on  its  way  to  the 
outside. 

The  duration  of  an  attack  of  renal  colic  is  subject  to  great 
variation,  and  may  be  from  a  few  hours  to  several  days.  As 
a  rule,  renewed  attacks  of  renal  colic  occur  after  a  longer  or 
shorter  interval,  because  frequently  several  calculi  are  present  in 
the  pelvis  of  the  kidney,  or  the  calculi  have  returned  from  the 
ureter  into  the  pelvis  of  the  kidney,  subsequently  to  resume  their 
passage  to  the  ureter.  Kot  rarely  patients  suiFer  from  attacks  of 
renal  colic  for  many  years  and,  at  times  with  greater,  at  other 
times  with  less  severity,  even  throughout  life.  An  attack  of  renal 
colic  is  not,  as  a  rule,  fatal.  Serious  dangers  may  arise  when  a 
renal  calculus  cannot  pass  upward  or  downward  in  the  ureter,  for 
there  may  then  result  inflammation,  gangrene,  and  rupture  of  the 
ureter,  with  rapidly  fatal  peritonitis.  If  a  renal  calculus  com- 
pletely occludes  the  ureter,  the  urine  stagnates  in  the  pelvis  of  the 
kidney,  and  acute  hydronephrosis  develops,  and  at  times  gives  rise 
to  a  palpable  renal  tumor. 

That  an  attack  of  renal  colic  is  due  to  the  presence  of  a 
calculus  will  become  demonstrated  with  certainty  only  when  renal 
calculi  are  passed  with  the  urine.  Suspicion  will,  naturally,  always 
be  aroused  if  the  urine  contains  considerable  crystalline  sediment, 
from  whose  nature  conclusions  may  at  the  same  time  be  formed 
as  to  the  chemic  constitution  of  the  renal  calculi.  In  rare  in- 
stances calculi  are  passed  with  the  urine  without  giving  rise  to 
any  symptoms,  most  commonly  in  elderly  women,  but  I  have 
observed  this  occurrence  at  times  also  in  men,  although  the  cal- 
culi were  almost  as  large  as  lentils.  For  this  to  take  place  the 
urinary  passages  must  be  of  a  certain  size  and  the  musculature 
be  relaxed. 

Prognosis. — The  prognosis  of  renal  calculi  is  not  unfavorable 
in  the  sense  that  death  but  rarely  results.  With  regard  to  perma- 
nent recovery,  the  conditions  are  naturally  different,  and  frequently 
there  is  renewed  formation  of  calculi  as  soon  as  the  old  calculi 
have  been  expelled.      The  conditions  become  serious  when  the 


446  GEmTO-URINARY  ORGANS 

kidneys  are  profoundly  involved  in  consequence  of  the  formation 
of  calculi,  in  the  form  of  either  purulent  pyelonephritis  or  con- 
tracted kidney. 

Treatment. — The  treatment  of  renal  calculi  varies  in  accord- 
ance with  the  chemic  constitution  of  the  precipitates.  In  the 
presence  of  uratic  calculi  experience  has  taught  the  wisdom  of 
interdicting  the  use  of  alcohol  as  largely  as  possible,  encouraging 
active  physical  exercise  in  the  open  air,  and  restricting  the  use  of 
meat,  although  the  earlier  view  is  incorrect  that  generous  use  of 
meat  gives  rise  directly  to  increased  formation  of  uric  acid  in 
the  body.  All  substances  rich  in  nuclein-bodies  (thymus,  spleen, 
brain,  lymphatic  glands,  liver,  kidneys)  are  to  be  avoided  particu- 
larly, because  uric  acid  is  derived  from  them.  In  order  to  diminish 
the  acidity  of  the  urine  vegetables  and  fruit  should  be  taken  in 
abundance.  It  has  of  late  become  the  fasliion  to  eat  oranges  in 
considerable  amount.  It  is  well  for  the  patient  to  drink  daily  a 
bottle  of  an  alkaline  or  carbonated  water,  among  which  those  of 
Fachingen,  Obersalzbrunn,  Ems,  Vichy,  Wiesbaden,  Giesshiibel, 
Bilin,  may  be  mentioned.  The  use  of  tepid  baths  (28°  R. — 35° 
C — 95°  F.)  twice  daily  generally  mitigates  such  symptoms  as  may 
be  present.  Attempts  have  further  been  made  to  effect  solution  of 
uratic  calculi  by  medicaments,  although  the  possibility  of  such  a 
result  has  not  been  demonstrated  with  certainty,  because  these  sol- 
vents pass  into  the  urine  in  such  small  amount  that  a  solution  of 
excreted  uric  acid  can  scarcely  be  conceived.  Among  such  sol- 
vents may  be  mentioned  the  following  :  lithium  carbonate,  lithium 
benzoate,  lithium  salicylate,  lithium  citrate,  lithium  bromid  (of 
each,  0.5 — 7^  grains — tlirice  daily  in  a  wine-glassful  of  soda-water), 
benzoic  acid  (0.5 — 7^  grains — thrice  daily),  magnesium  borocitrate 
(1.0  :  100 — 15  grains  :  3  fiuidounces;  1  tablespoonful  every  hour), 
piperazin  (0.5 — 7^  grains — thrice  daily),  lysidin  (from  1.0  to  5.0: 
500 — from  15  to  75  grains  :  1  pint — of  soda-water  daily),  uricedin 
(0.5 — 7^  grains — four  times  daily),  urotropin  (1.0 — 15  grains — 
thrice  daily). 

Well-to-do  patients  may  be  recommended  courses  of  treat- 
ment at  the  baths  during  the  summer,  such  as  the  alkaline  baths 
of  Carlsbad,  Marienbad,  Tarasp,  Ems,  ^^'iesbaden,  Vichy,  the 
lithium-sj)rings  of  Assmannsliausen,  Baden,  Salzschlirf,  and  the 
springs  of  Wildungen  and  Contrexeville.  Individuals  with  o.ralatc- 
calculi  should  observe  the  same  mode  of  life  as  those  with  uratic 
calculi,  and  they  should  be  especially  careful  to  avoid  such  vege- 
tables as  contain  an  abundance  of  calcium  oxalate.  These  include 
particularly  spinach,  tomatoes,  sorrel,  rhubarb,  cocoa,  and  tea. 
Xanfhin-cdlculi,  cj/sitin-calcidi,  and  mdigo-caleuVi  require  similar 
therapeutic  measures.  The  conditions,  however,  are  quite  different 
in  the  treatment  of  phosphatie  calcu/i  and  carhonate-calcuU.  As 
these  occur  only  in  alkaline  urine,  efforts  should  be  made  to  render 


CARCINOMA    OF  PELVIS  OF  KIDNEY  AND   THE   URETER    447 

the  reaction  of  the  urine  acid.  The  ingestion  of  vegetables  and 
fruit  should  therefore  be  restricted.  In  addition,  mineral  acids 
should  be  administered  internally,  as,  for  instance,  hydrochloric 
acid  and  nitric  acid  : 

R   Dilute  hydrochloric  acid, 

Dilute  nitric  acid,  each,      2.0  (30  minims) ; 

Distilled  water,  180.0  (6  fluidounces)  ; 

Sirup  of  red  raspberry,  15.0  (J  fluidounce). — M. 

Dose :  15  c.c.  (1  tablespoonful)  every  two  hours. 

A  coexisting  pyelitis  naturally  will  also  be  favorably  influenced 
by  the  employment  of  alkaline  waters.  If  renal  colic  develops, 
a  hot  cataplasm  should  be  applied  to  the  loin,  weak  tea  or  an  acid 
water  should  be  taken  abundantly  in  order  to  increase  the  elimina- 
tion of  urine  and  to  favor  the  passage  of  the  calculus,  and,  if  the 
pain  be  severe,  a  subcutaneous  injection  of  morphin  may  be 
given  : 

R  Morphin  hydrochlorate,  0.3  (40  grains) ; 

Glycerin, 

Distilled  water,  each,  5.0  (75  minims). — M. 

Dose :  From  0.25  to  0.5  (4  to  8  minims)  subcutaneously. 

Of  late,  the  operative  removal  of  renal  calculi  has  been  under- 
taken with  brilliant  results.  This  matter  will  arise  for  considera- 
tion when  the  symptoms  due  to  tlie  calculus  are  so  persistent  and 
so  severe  as  to  render  life  unendurable  to  the  patient.  Under 
such  circumstances  the  kidney  and  its  pelvis  will  be  incised 
— nephrolithotomy ;  or  the  pelvis  alone  will  be  opened — pyelolitli- 
otoray — and  the  calculi  removed.  In  addition,  impaction  of  a 
calculus  in  the  ureter  may  furnish  the  indication  for  exposure  of 
the  ureter,  witli  an  eifort  to  force  the  calculus  upward  or  downward 
by  massage  with  the  fingers,  or,  should  this  fail,  the  ureter  may  be 
opened  in  order  to  remove  the  stone — ureterolithotomy.  Finally, 
operation  will  be  resorted  to  when  the  calculi  in  the  renal  pelvis 
have  induced  advanced  pyelonephritis.  In  accordance  with  the 
condition  of  the  kidney  the  operation  of  nephrotomy  or  of  nephrec- 
tomy will  then  be  performed.  In  cases  of  doubtful  diagnosis 
exploratory  incision  of  the  kidney  has  even  been  practised. 


CARCINOMA  OF  THE  PELVIS  OF  THE  KIDNEY 
AND  THE  URETER. 

Primary  carcinoma  of  the  pelvis  of  the  kidney  or  the  ureter 
is  uncommon.  Generally  the  new-growth  is  a  secondary  carcinoma 
which  has  invaded  the  pelvis  of  the  kidney  from  the  kidney  itself 
or  from  the  neighborhood.  The  symptoms  are  those  of  carcinoma 
of  the  kidney. 


448  GENITO-URINARY  ORGANS 

PARASITES  OF  THE  PELVIS  OF  THE  KIDNEY. 

Rarely  the  palisade-worm — Strongylus  gigas — is  found  in  the 
pelvis  of"  the  kidney.  It  resembles  a  spool-worm,  except  that  it 
is  supplied  with  six  instead  of  three  nipple-like  papilke  around 
the  buccal  orifice.  It  gives  rise  to  the  symptoms  of  pyelitis,  and 
causes  pain  in  the  kidney,  vesical  tenesmus,  })yuria,  and  hematuria. 
In  addition,  the  Distoma  haematobium  ^  also  occurs  in  the  pelvis  of 
the  kidney.  It  gives  rise  to  the  same  clinical  symptoms  as  the 
palisade-worm,  and  may  be  recognized  from  the  appearance  of 
distoma-ova  in  the  urinary  sediment.  The  eggs  are  oval,  and  in 
the  neighborhood  of  one  pole  possess  a  lateral  process.  The  para- 
sites may  be  acquired  by  the  ingestion  in  the  Orient — as,  for 
instance,  in  Egypt — of  water  containing  ova. 


III.   DISEASES   OF  THE   URINARY   BLADDER. 


INFLAMMATION  OF  THE  URINARY  BLADDER 
(UROCYSTITIS). 

Ktiology. — Inflammation  of  the  urinary  bladder  is  most 
commonly  induced  by  bacteria,  while  toxic  urocystitis  is  far  less 
common.  Among  the  bacteria  Streptococcus  and  Staphylococcus 
pvogenes — particularly,  however,  the  Bacterium  coli,  at  times  also 
tubercle-bacilli,  gonococci,  and  proteus — may  be  mentioned  as  the 
exciting  agents  of  the  inflammatory  process.  Not  rarely  mixed 
infection  has  taken  place,  several  varieties  of  bacteria  occurring 
together.  Among  the  contributory  causes  for  infection  of  the  urinary 
bladder  with  bacteria,  exposure  to  cold  should  be  mentioned  in  the 
first  place — refrigeratory  {rheumatic)  urocystitis.  Exposure  of  the 
abdomen  while  the  body  is  the  seat  of  perspiration,  wetting  of 
the  clothing,  cold  baths  and  spongings,  and  insufficient  clothing 
are  not  rarelv  assigned  by  the  patient  as  causes  of  the  disorder. 
Traumatic  urocystitis  may  be  induced  by  external  or  internal 
injuries;  as,  for  instance,  by  a  fi^ll,  a  blow,  a  kick  in  the  hypo- 
gastrium,  the  introduction  of  a  catheter  and  other  surgical 
instruments,  even  when  these  have  been  sterilized.  LTrocystitis 
arises  with  great  frequency  by  extension  from  adjacent  disease. 
Chronic  gonorrhea  involving  the  posterior  portion  of  the  urethra 
often  causes  urocystitis,  and  many  cases  of  apparently  spontaneous 
origin  are  dependent  upon  an  insidious,  almost  forgotten  chronic 
gonorrheal  urethritis.  Urocystitis,  however,  also  frequently  cora- 
^  Schistosoma  haematobium. — A.  A.  E. 


INFLAMMATION  OF  THE   URINARY  BLADDER  449 

plicates  acute  gonorrheal  urethritis,  parametritis,  and  perimetritis, 
oophoritis,  proctitis,  prostatitis,  pyelitis,  and  nephritis. 

Previous  disease  of  the  bladder  also  is  a  common  cause  for  uro- 
cystitis,  which  thus  is  encountered  in  association  with  vesical  calculi 
and  tumors  and  tuberculosis  of  the  bladder.  Urocystitis  occurs  with 
particular  frequency  in  association  Avith  paralysis  of  the  bladder, 
for  when  the  sphincter  vesicae  is  paralyzed  the  possibility  arises 
for  the  entrance  of  bacteria  from  the  urethra  into  the  bladder, 
with  the  development  of  inflammation.  Urocystitis  occurs  at  times 
in  the  course  of  infectious  diseases  (typhoid  fever,  pneumonia, 
articular  rheumatism,  cholera,  dysentery,  septicopyemia).  Imme- 
diate infection  of  the  bladder  with  bacteria  may  be  effected  by 
means  of  catheters  and  other  surgical  instruments  if  these  are  not 
freed  from  bacteria  and  sterilized  before  introduction  into  the 
bladder ;  but  even  the  introduction  of  sterile  instruments  may  not 
be  unattended  Avith  danger  if  the  urethra  contains  bacteria  in 
considerable  number,  as  these  may  be  forced  into  the  bladder 
by  the  instrument  used.  Toxic  urocystitis  is  occasionally  observed 
after  the  ingestion  of  cantharides,  balsamics,  or  mineral  acids. 
Also,  the  injection  of  irritating  substances  into  the  urethra  not 
rarely  gives  rise  to  inflammation  of  the  bladder.  All  conditions 
attended  with  uHnary  stasis  favor  in  marked  degree  the  develop- 
ment of  urocystitis,  because  bacteria  readily  undergo  multiplication 
in  stagnant  urine.  For  this  reason  the  disorder  is  frequently 
observed  in  the  train  of  stricture  of  the  urethra  and  prostatic 
hypertrophy,  during  pregnancy,  in  association  with  flexion  of  the 
uterus,  constipation,  and  after  suppression  of  urine.  Urocystitis 
is  an  uncommon  disease  in  childhood,  but  it  is  particularly  fre- 
quent in  the  aged.  In  men  it  is  often  dependent  upon  senile 
hypertrophy  of  the  prostate  gland.  Experience  has  shown  that 
men  suffer  from  urocystitis  more  commonly  than  women. 

Anatomic  Alterations. — The  mucous  membrane  of  the  uri- 
nary bladder  when  inflamed  exhibits  redness,  swelling,  and  in- 
creased secretion  of  mucus.  In  the  presence  of  acute  urocystitis  the 
color  of  the  mucous  membrane  is  bright  red,  Avhile  in  the  presence 
of  chronic  inflammation  it  is  rather  brownish  red  or  reddish  gray. 
Frequently,  extravasations  of  blood  have  taken  place  into  the 
mucous  membrane,  which  then  presents  a  bloody  or  brownish, 
mottled  appearance,  and  in  case  of  chronic  inflammation  a  grayish 
or  a  blackish,  mottled  appearance.  The  swelling  of  the  mucous 
membrane,  in  cases  of  acute  inflammation,  depends  upon  serous 
infiltration,  while  in  cases  of  chronic  inflammation  it  is  due  to 
inflammatory  hyperplasia  of  the  tissues  of  tlie  mucous  membrane. 
The  inflammatory  hyperplasia  of  the  connective  tissue  not  rarely 
extends  to  the  muscular  co^t  of  the  bladder,  in  consequence  of 
which  the  latter  becomes  thickened  and  often  projects  into  the 
cavity  of  the  bladder  in  the  form  of  numerous  columns  (trabecular 

29 


450  GENITO-URINARY  ORGANS 

degeneration),  so  that  the  interior  of  the  bladder  suggests  the 
appearance  of  one  of  the  ventricles  of  the  heart. 

Often  the  cavity  of  the  bladder  is  altered,  the  viscus  being  either 
unusually  capacious  or  remarkably  small,  and  accordingly  a  distinc- 
tion has  been  made  between  eccentric  and  cooicentric  liyijertrojjhy  of 
the  bladder.  Occasionally  some  of  the  spaces  between  projecting  col- 
umns of  muscle  have  undergone  bulging,  and  pockets  (diverticula) 
of  greater  or  lesser  size  have  developed,  which  at  times  are  larger 
than  the  cavity  of  the  bladder  itself,  and  occasionally  contain 
urinary  calculi.  At  times  the  serous  membrane  of  the  bladder 
also  is  involved  in  the  inflammatoiy  thickening,  and  presents  a 
tendinous  and  turbid  appearance. 

Increased  secretion  of  nmcus  in  cases  of  inflammation  of 
the  bladder  is  attended  with  an  abundant  deposition  of  mucus 
and  considerable  admixture  of  mucus  with  the  urine.  The  urine 
contained  within  the  bladder  usually  presents  a  turbid,  a  mucous, 
a  purulent,  often  also  a  bloody,  appearance,  and  is  frequently 
offensive  in  odor  from  alkaline  decomposition.  Severe  inflam- 
mation of  the  bladder  is  at  times  attended  with  circumscribed 
accumulation  of  pus  in  the  wall  of  the  bladder — abscess  of  the 
urinary  bladder ;  or  there  may  be  purulent  inflammation  of  the 
serous  coat  of  the  bladder — pericystitis.  That  variety  of  uro- 
cystitis  in  which  fibrinous  membranes  form  upon  the  surface 
of  the  mucous  membrane  is  upon  the  whole  rare — pseudomem- 
branous urocystitis  {fibrinous  or  croupous  urocystitis).  Necrosis  also 
occurs  occasionally  upon  the  mucous  membrane — necrotic  or  pseudo- 
diphtheric  urocystitis  ;  and  this  appears  in  the  form  of  grayish-green 
or  blackish  masses,  after  exfoliation  of  which  ulcers  remain  upon 
the  mucous  membrane.  At  times  the  ulceration  extends  deeply, 
and  rupture  of  the  Ijladder  may  take  place,  with  the  development 
of  a  vesical  fistula.  Rupture  may  take  place  into  the  vagina,  the 
rectum,  the  peritoneal  cavity,  or  externally. 

Symptoms  and  Diagnosis. — In  accordance  with  the  dura- 
tion of  inflammation  of  the  bladder  a  distinction  is  made  between 
acute  and  chronic  urocystitis.  The  latter  may  persist  at  times  for 
many  years.  Both  varieties  naturally  have  in  common  the  two 
most  important  symptoms — derangement  of  micturition  and  altera- 
tions in  the  urine. 

Acute  urocystitis  is  often  first  indicated  by  difficulty  in  micturi- 
tion. The  patients  suffer  from  excessively  frequent  vesical  tenes- 
mus, and  the  act  of  micturition  itself  is  attended  with  severe  pain, 
with  especial  frequency  and  intensity  at  the  conclusion  of  the  act. 
If  micturition  is  repeated  at  short  intervals,  only  a  few  cubic 
centimeters  of  urine  are  voided  each  time,  and  frequently  only  a 
few  drops.  In  addition,  the  patients  often  com]dain  of  a  heavy 
and  generally  also  markedW  painful  feclinfj  in  the  hypogastrium, 
which  is  greatly  increased  by  pressure  in  this  region.     At  times 


INFLAMMATION  OF  THE   UBINABY  BLADDEB  451 

retention  of  urine  occurs,  either  because  the  mucous  membrane  in 
the  neighborhood  of  the  urethral  orifice  is  greatly  swollen  as  a 
result  of  the  inflammatory  process,  or  in  consequence  of  spasm  of 
the  sphincter  of  the  bladder.  The  urine  presents  a  variable 
appearance  in  accordance  with  the  nature  of  the  inflammatory 
process.  In  the  mildest  cases,  which  may  be  designated  raucous 
urocystitis  (or  less  appropriately  catarrh  of  the  urinary  bladder), 
the  urine  contains  an  excessive  amount  of  mucus,  so  that,  on  stand- 
ing, an  exceedingly  dense  and  extensive  cloud  of  mucus  forms 
at  the  bottom  of  the  vessel.  On  microscopic  examination  of  the 
urinary  sediment  a  small  number  of  round  cells  are  found,  and 
often  a  large  number  of  desquamated  epithelial  cells  from  the 
mucous  membrane  of  the  bladder,  so  that  the  condition  might  be 
designated  desquamative  catarrh  of  the  urinary  bladder.  At  the  same 
time  the  urine  retains  its  acid  reaction,  and  in  some  cases  it  may 
be  even  more  than  ordinarily  acid. 

The  designation  supjmrative  urocystitis  [purulent  catarrh  of 
the  urinary  bladder)  may  be  applied  to  cases  in  which  the  urine 
contains  an  abundance  of  pus-corpuscles — pyuria.  On  standing, 
a  greenish-gray  sediment  collects  at  the  bottom  of  the  vessel,  con- 
sisting, in  addition  to  pus-corpuscles,  of  desquamated  epithelial 
cells  from  the  mucous  membrane  of  the  bladder.  In  the  presence 
of  purulent  urocystitis  also  the  urine  often  retains  its  acid  reac- 
tion, while  in  other  instances  alkaline  fermentation  takes  place, 
as  indicated  by  the  disagreeable,  pungent,  urinous  odor.  Under 
such  conditions  definite  crystalline  formations  also  frequently 
appear  in  the  urinary  sediment,  especially  the  coffin-lid  crystals 
of  ammonio-magnesium  phosphate  (also  known  as  triple  phos- 
phate), and  the  thorn-apple  varieties  of  acid  ammonium  urate. 

At  times  the  pus  is  transformed  into  a  viscid,  mucoid  mass,  and  on 
microscopic  examination  it  is  found  tliat  tlie  pus-corpuscles  are  greatly- 
swollen  and  transformed  into  almost  homogeneous,  polynuclear  cells. 
Sometimes  such  a  mass  interferes  with  micturition,  and  if  a  catheter  be 
introduced  into  the  bladder  the  mass  may  be  evacuated,  often  with  great 
difficulty,  when  a  greater  or  lesser  amount  of  urine  readily  escapes.  At 
times  the  urine  acquires  a  fecal  odor,  obviously  from  the  penetration  into 
the  bladder  of  gas  from  adjacent  loops  of  bowel.  The  odor  of  hydrogen 
sulphid — hydrotliionuria — has  also  been  observed.  Should  the  urine  con- 
tain sugar,  gas  may  be  generated  in  the  bladder  from  its  fermentation — 
pneumaturia. 

At  times  the  urine  contains  blood  in  addition  to  pus — hemor- 
rhagic urocystitis.  In  part  the  red  blood-corpuscles  are  rather 
uniformly  admixed  with  the  urine,  and  impart  to  it  a  dirty-red, 
almost  clay-like  color,  and  in  part  blood-clots  are  found  in  the 
urinary  sediment.  Fortunately,  the  cases  are  rare  in  which 
necrotic  vesical  mucous  membrane  becomes  detached  and  is  evac- 
uated with  the  urine  in  larger  or  smaller  shreds.  Pseudomem- 
branous cystitis  is  at  times  attended  with  the  presence  of  fibrinous 


452  GENITO-URINARY  ORGANS 

membrane  in  the  urine.  Tlie  amount  of  urine  in  cases  of  inflam- 
mation of  the  bladder  is  often  increased,  probably  in  consequence 
of  reflex  irritation  of  the  secretory  nerves  of  the  kidneys,  and 
accordingly  the  specific  gravity  of  the  urine  is  diminished.  The 
general  condition  may  remain  unchanged,  apart  from  the  fact  that 
sleep  may  be  greatly  disturbed  l)y  the  annoying  tenesmus.  In 
some  cases,  however,  slight  fever  may  be  present.  The  patients 
lose  their  appetite,  complain  of  increased  thirst,  and  rapidly  be- 
come pale  and  miserable. 

Acute  urocystitis  may  extend  over  a  few  days,  or  it  may  per- 
sist for  from  four  to  eight  weeks.  As  a  rule,  recovery  takes  place 
gradually,  the  difficulty  in  micturition  growing  progressively  less, 
while  the  urine  becomes  more  and  more  clear,  and  regains  its 
natural  appearance.  Should  an  abscess  of  the  wall  of  the  blad- 
der develop,  symptoms  of  severe  general  septicemia  frequently 
appear,  and  should  the  urocystitis  become  complicated  by  a  peri- 
uroeystitis  the  region  of  the  bladder  will  be  extremely  sensitive  to 
touch. 

Chronic  urocystitis  either  develops  in  the  sequence  of  acute 
inflammation  of  the  bladder,  if  this  recurs  frequently,  and  partic- 
ularly if  recurrence  takes  place  before  recovery  from  the  preceding 
attack  has  completely  resulted ;  or  it  appears  from  the  outset  in  a 
chronic  and  torpid  form.  The  latter  circumstance  depends  in  jiart 
upon  the  causative  factors.  Thus,  tumors,  calculi,  and  tuberculo- 
sis of  the  bladder,  as  well  as  prostatic  hypertrophy  and  stricture 
of  the  urethra,  usually  give  rise  to  chronic  urocystitis  from  the 
outset.  Patients  with  chronic  inflammation  of  the  bladder  com- 
plain, as  a  rule,  of  vesical  tenesmus  and  jmin  in  micturition,  although 
the  symptoms  are  generally  less  pronounced  than  in  cases  of  acute 
urocystitis.  The  urine  contains  pus  or  blood,  and  gradually 
acquires  an  alkaline  reaction.  Fever  is  generally  absent,  except 
when  acute  exacerbations  occur,  while  strength  is  gradually  lost, 
and  eventually  death  may  result  from  exhaustion.  At  times 
putrid  urinary  products  are  absorbed  from  the  bladder,  and  uri- 
nar If. septicemia  develops  (fever,  stupor,  sweats,  exhaustion).  The 
inflammatory  process  may  also  extend  from  the  bladder  to  the 
pelvis  of  the  kidneys,  and  give  rise  to  pjyelonephritis  and  its  con- 
sequences. 

Chronic  urocystitis  becomes  particularly  troublesome  when 
complicated  by  paralysis  of  the  sphincter  of  the  bladder.  The 
patients  are  then  unable  to  retain  the  urine,  Avhich  is  passed  into 
the  clothing  and  the  body-linen,  and  they  diffuse  a  j)enetrating, 
urinous  odor,  while  at  the  same  time  the  soiled  clothing  ac- 
quires a  reddish-yellow  color  where  it  is  saturated,  and  in  this 
way  the  condition  of  incontinence  may  become  manifest  even  to 
the  ordinary  observer.  When  eccentric  hypertrophy  of  the  bladder 
has  developed  in  the  course  of  chronic  urocystitis  the  bladder  may 


INFLAMMATION  OF  THE   URINARY  BLADDER  453 

be  felt  above  the  pubes  and  is  never  completely  emptied.  In  the 
presence  of  concentric  hyperti'ophy  of  the  bladder  the  viscus  must 
be  emptied  at  short  intervals,  as  it  is  capable  of  containing  only  a 
small  amount  of  fluid,  and,  besides,  the  bladder  can  frequently  be 
felt  through  the  vagina  or  the  rectum  as  a  hard,  globular  body. 
The  diagnosis  of  acute  and  chronic  urocystitis  is  not  difficult  on 
account  of  the  readily  appreciable  symptoms,  but  diagnostic  diffi- 
culty may  arise  in  the  determination  of  the  causes  of  the  inflam- 
matory process. 

Prognosis. — The  prognosis  of  inflammation  of  the  bladder 
depends  essentially  upon  the  curability  or  incurability  of  the  caus- 
ative factors.  Cryptogenetic  chronic  urocystitis  in  young  persons 
deserves  particular  consideration,  for  it  is  often  dependent  upon 
tuberculosis. 

Treatment. — The  following  measures  for  the  prophylaxis  of 
inflammation  of  the  bladder  are  particularly  to  be  mentioned  : 
Avoidance  of  exposure  of  the  abdomen  when  the  body  is  heated, 
introduction  into  the  bladder  of  only  thoroughly  sterilized  instru- 
ments, careful  and  thorough  treatment  of  urethritis,  and  care  in 
the  use  of  cantharides,  balsamics,  and  other  agents  capable  of 
causing  irritation  of  the  bladder.  In  the  treatment  of  all  varieties 
of  urocystitis  the  first  place  should  be  given  to  the  mode  of  life  and 
the  diet.  Persons  with  acute  catarrh  of  the  bladder  should  re- 
main in  bed,  and  those  with  chronic  catarrh  should  protect  the 
hypogastrium  against  cold  by  the  application  of  a  woollen  abdom- 
inal bandage.  Sudden  cooling  of  the  hypogastric  region  is  always 
injurious.  The  use  of  baths,  at  a  temperature  of  30°  R.  (37.5°  C. 
— 99.5°  F.),  for  from  fifteen  to  thirty  minutes,  from  twice  to  four 
times  weekly,  may  be  advised.  After  the  bath  warmed  clothing 
should  be  put  on.  The  bed,  also,  should  be  warmed.  All  irri- 
tating articles  of  food  and  drinh  should  be  avoided,  particularly 
strong  alcoholics,  beer,  spices,  acids,  fruit,  and  asparagus,  the  last 
of  which  readily  causes  irritation  of  the  urinary  organs.  The  use 
of  boiled  milk  is  particularly  to  be  recommended,  to  each  glass  of 
which  a  tablespoonful  of  lime-ivater  may  be  advantageously  added. 
The  use  of  weak  tea  also  may  be  recommended.  If  thirst  be 
marked,  a  bottle  of  Vichy,  Fachingen,  Ems,  Wildungen,  Gies- 
shiibler,  or  Bilin  water  daily  should  be  permitted.  In  cases  of 
acute  inflammation  of  the  bladder  internal  treatment  must  suffice, 
and  use  be  made  particularly  of  astringents,  disinfectants,  or  bal- 
samics. Among  astringents,  I  prefer  a  tea  of  uva  ursi  leaves, 
making  use  less  commonly  of  tannic  acid,  arbutin,  and  other 
astringents  : 

R  Uva  ursi  leaves,  100.0    (3  fluidounces). 

Dose :  1  tablespoonful  to  a  large  cup  of  water  as  an  infusion  thrice 
daily.' 


454  GENITO-URINARY  ORGAN'S 

In  addition,  disinfectants  may  be  administered  at  the  same  time, 
and  of  these  I  prefer  salol  : 

K  Salol,  1.0    (15  grains); 

Saccharin,  0.02  (^  grain). — M. 
Make  10  such  powders. 
Dose  :  1  powder  every  three  hours. 

Saccharin  is  advantageously  selected  as  a  corrective  for  salol,  because 
antifermentative  properties  have  been  ascribed  to  it  also.  Should  the  urine 
acquire  a  greenish  or  blackish  color  after  the  use  of  salol,  this  will  be  no 
reason  for  the  withdrawal  of  the  drug;  but  the  conditions  are  otherwise  if 
albumin  in  considerable  amount  appears  in  the  urine.  The  remedy  may  be 
continued  for  from  ten  days  to  two  weeks.  In  my  experience,  salicylic  acid 
(1.0 — 15  grains — every  two  hours)  and  sodium  salicylate  (1.0 — 15  grains — 
every  two  hours)  are  less  reliable  in  action  than  salol. 

Among  balsamics,  the  first  place  should  be  given  to  oil  of  tur- 
pentine, which  likewise  may  be  employed  for  one  or  two  weeks  : 

R  Oil  of  turpentine,  10.0    (2^  fluidrams). 

Dose :  10  drops  in  milk  thrice  daily. 

When  the  urine  is  highly  alkaline,  jjotassiuni  chlorate  has  been 
recommended,  although  my  personal  experience  with  it  is  by  no 
means  favorable: 

R  Solution  of  potassium  chlorate,  10.0 :  200  (2^  drams :  6^  fluidounces). 
Dose:  15  c.c.  (1  tablespoonful)  thrice  daily  after  meals. 

Potassium  chlorate  should  be  given  only  when  the  stomach  contains 
food,  and  never  when  this  viscus  is  empty,  as  in  the  latter  event  toxic  symp- 
toms might  be  readily  induced  (dissolution  of  red  corpuscles  and  its  conse- 
quences). 

The  internal  treatment  of  chronic  inflammation  of  the  bladder 
is  the  same  as  that  of  acute  cystitis,  although  in  obstinate  cases 
local  treatment  of  the  bladder  with  irrigations  should  be  recom- 
mended additionally.  Katurally,  the  latter  will  effect  complete 
and  permanent  success  only  if  previously  the  causal  indications 
have  been  met,  and,  for  instance,  vesical  calculi  removed,  pros- 
tatic hypertrophy  or  stricture  of  the  urethra  relieved,  and  the 
like. 

For  irrigation  of  the  bladder  an  ordinary  irrigator  and  a  simple  catheter 
are  employed.  Fluid  at  the  temperature  of  the  body  and  under  moderate 
pressure  is  permitted  to  flow  into  the  bladder  until  the  patient  complains 
of  a  sense  of  fulness  or  the  fundus  of  the  bladder  can  be  felt  above  the 
symphysis  of  the  pubes.  Tlie  employment  of  a  double-current  catheter 
appears  less  serviceable,  because  the  bladder  is  not  distended  and  com- 
pletely filled,  so  that  some  portions  of  the  wall  of  the  bladder  and  diverticula 
readily  remain  unirrigated.  As  the  bladder  when  the  seat  of  chronic  inflam- 
mation often  has  a  tendency  to  contract  gradually  and  undergo  progressive 
diminution  in  size,  it  is  advantageous  from  time  to  time  to  cause  marked 
distention  of  the  viscus  by  completely  filling  it.  As  an  irric/afinr/  fluid  a 
solution  of  silver  nitrate  should  be  given  first  place.  A  weak  solution  (0.2: 
500 — 3  grains ;  16  fluidounces)  is  begun  with,  and  the  strength  is  gradually 
increased  to  5.0  :  500  (Ih  grains :  16  fluidounces).  Tannic  acid  and  borif  acid 
(from  2.0  to  10.0 :  500 — from  30  grains  to  2 J  drams :  16  fluidounces)  are  also 


CARCINOMA   OF  THE  URINARY  BLADDER  455 

worthy  of  recommendation.  If  the  urine  contain  large  amounts  of  mucus, 
the  bladder  should  be  irrigated  with  sodium  chlorid  (5.0 :  500 — 75  grains  : 
16  fluidounces).  I  rarely  employ  disinfectants;  in  particular  care  should 
be  exercised  in  the  use  of  carbolic  acid  and  mercuric  chlorid,  as  dangerous 
intoxication  may  readily  be  induced  thereby. 

In  obstinate  cases  of  chronic  inflammation  of  the  bladder  inci- 
sion of  the  bladder — urocystotomy — has  even  been  resorted  to, 
with  direct  treatment  of  the  wall  of  the  bladder,  and  recently 
curettage  of  the  mucous  membrane.  In  the  presence  of  chronic 
catarrh  of  the  bladder  courses  of  treatment  at  the  springs  have 
also  been  followed.  Waters  containing  calcium  sulphate  have 
been  particularly  recommended,  such  as  Carlsbad,  Vichy,  Ems, 
Neuenahr,  Contrexeville,  Wildungen.  Also  indifferent  thermal 
springs  (Pf  affers,  Ragaz,  Wildbad,  Gastein)  are  frequently  useful. 
If  retention  of  urine  occur  in  the  course  of  inflammation  of 
the  bladder,  the  urine  should  be  withdrawn  by  means  of  a 
catheter.  Also  in  cases  of  eccentric  hypertrophy  of  the  bladder 
catheterization  should  be  practised  systematically  in  order  to  evac- 
uate the  bladder  completely  from  time  to  time.  In  cases  of  con- 
centric hypertrophy  of  the  bladder  the  patient  should  be  urged  to 
retain  the  urine  for  as  long  a  time  as  possible,  in  order  to  effect 
gradual  distention  of  the  viscus.  Marked  vesical  tenesmus  can 
be  effectually  relieved  by  a  subcutaneous  injection  of  morphin  or 
by  suppositories  of  morphin  : 

B  Morphin  hydrochlorate,  0.1  (1|  grains) ; 

Cocoa-butter,  sufficient  to  make  10  suppositories. 
Dose :  1  suppository  once  or  twice  daily. 

CARONOMA  OF  THE  URINARY  BLADDER* 

Ktiology. — Carcinoma  of  the  urinary  bladder  is  generally 
secondary,  and  arises  frequently  by  direct  extension  from  adjacent 
organs  (rectum,  prostate  gland,  uterus).  The  disorder  is,  on  the 
whole,  an  uncommon  one,  and  it  almost  always  occurs  after  the 
thirtieth  year  of  life,  and,  as  experience  has  shown,  more  com- 
monly in  women  than  in  men. 

Anatomic  Alterations. — Carcinoma  of  the  bladder  is  most 
commonly  seated  at  the  neck  and  at  the  base  of  the  bladder.  At 
times  the  morbid  process  consists  in  extensive  carcinomatous  in- 
filtration of  the  wall  of  the  bladder,  particularly  of  the  submu- 
cosa,  while  at  other  times  it  gives  rise  to  a  circumscribed  neo- 
plasm, attached  to  the  interior  of  the  bladder  by  means  either  of 
a  broad  base  or  of  a  slender  pedicle.  The  new-growth  may  be 
an  epithelial  carcinoma  (cancroid),  or  a  villous  carcinoma,  or  a 
scirrhus  ;  least  commonly  it  appears  as  a  medullary  carcinoma  or 
colloid  carcinoma.  jSTot  rarely  the  carcinomatous  tissue  under- 
goes disintegration,  with  the  development  of  a  carcinomatous 
ulcer.     As  a  result  of  this  process  almost  all  the  new-growth  may 


456  GENITO-URINARY  ORGANS 

be  destroyed,  so  that  the  nature  of  the  neoplasm  will  at  times 
be  recoi^nizable  only  from  the  earcinomatous  infiltration  of  its 
margins.  Under  sueli  circumstances  rupture  of  the  bladder  into 
adjacent  organs  (rectum,  vagina,  abdominal  wall,  perineum)  may 
also  take  place.  The  mucous  membrane  of  the  bladder  is  almost 
always  in  a  state  of  chronic  inflammation. 

Symptoms  and  Diagnosis. — Carcinoma  of  the  bladder  is 
often  concealed  for  a  long  time  behind  the  symptoms  of  chronic 
cystitis,  and  at  times  the  true  condition  is  disclosed  only  on  post- 
mortem examination.  Chronic  cystitis  should  always  arouse  sus- 
picion as  to  its  carcinomatous  nature  if  the  symptoms  of  inflam- 
mation of  the  bladder  appear  to  develop  spontaneously  in  an 
elderly  person,  in  the  absence  of  signs  of  the  presence  of  a  calculus 
or  of  prostatic  bypertrophy,  if  pallor  and  emaciation  increase 
rapidly,  and  the  inguinal  glands  are  indurated  and  enlarged  in 
consequence  of  carcinomatous  degeneration.  Frequently  hema- 
turia occurs,  and  this  may  be  repeated  from  time  to  time  and 
accelerate  in  marked  degree  the  pallor  and  the  debility.  At 
times  the  bleeding  is  so  profuse  and  uncontrollable  as  to  cause 
death  from  hemorrhage. 

The  diagnosis  of  carcinoma  of  the  bladder  will  be  positive 
only  wdien  undoubted  masses  of  carcinomatous  tissue  can  be 
demonstrated  in  the  urinary  sediment,  or  when  the  new-growth 
becomes  accessible  to  palpation  or  inspection.  On  examination 
of  the  urinary  sediment  it  will  be  important  to  learn  whether  an 
unusually  large  number  of  multinucleated  epithelial  cells  are 
present,  or  Avhether  perhaps  macroscopically  visible  shreds  and 
flocculi  of  carcinomatous  tissue  can  be  found  in  the  urine.  Only 
rarely  will  it  be  possible  to  feel  a  carcinomatous  growth  of  the 
bladder  as  a  nodular  tumor  through  the  abdominal  walls.  Most 
commonly  it  can  be  palpated  on  examination  through  the  rectum 
or  vagina,  or  by  means  of  a  catheter.  In  the  last  event,  one  must 
be  prepared  to  detect  an  earthy  scratching  with  the  catheter, 
because  not  rarely  the  surface  of  the  new-groAvth  is  covered  with 
a  crystalline  sediment.  At  times  portions  of  new-growth  remain 
impacted  in  the  fenestrum  of  the  catheter,  and  these  should  be 
carefully  examined  microscopically.  Rarely,  in  women  portions 
of  tumor  are  observed  to  project  into  the  urethra.  Recently  an 
element  of  accuracv  and  certainty  has  been  added  to  the  diagnosis 
of  diseases  of  the  bladder  through  the  introduction  of  illuminating 
apparatus  into  that  viscus — urocystoscopy — which  renders  possible 
thorough  examination  of  the  interior  of  the  bladder. 

Patients  with  carcinoma  of  the  bladder  often  suifer  from  severe 
pain  in  the  hypogastric  region,  which  is  prone  to  appear  ])articularly 
durino:  the  ni<xlit,  and  not  rarelv  radiates  for  considerable  distances 
(loins,  thigh).  At  times  retention  of  urine  occurs,  but  incontmence  of 
urine  also  may  develop  if  the  tumor  has  invaded  the  orifice  of  the 


FOREIGN  BODIES  IN  THE   URINARY  BLADDER        457 

urethra,  and  has  destroyed  the  sphincter  of  the  bladder.  Febrile 
symptoms  are  not  rarely  present,  particularly  if  the  arine  is  greatly 
decomposed.  Death  generally  occurs  within  a  year  as  the  result 
of  exhaustion  or  urinary  septicemia  or  rupture  of  the  bladder, 
and  at  times  also  of  uncontrollable  hemorrhage.  If  the  orifices 
of  the  ureters  are  obstructed  by  the  new-growth,  hydronephrosis, 
pyelonephritis,  pyonephrosis,  and  septicemia  may  readily  develop. 
Prognosis  and  Treatment. — The  prognosis  of  carcinoma 
of  the  bladder  is  still  extremely  grave,  although  it  has  been  ren- 
dered rather  more  favorable  in  recent  years  since  successful 
attempts  have  been  made  to  remove  the  new-growth  by  operative 
means.     No  result  can  be  effected  by  internal  remedies. 

PARASITES  OF  THE  URINARY  BLADDER. 

Among  animal  parasites  the  presence  of  a  free  eckinococcus-cyst 
in  the  bladder  has  been  recorded  in  one  case.  In  the  Orient,  par- 
ticularly in  Egypt,  the  Distoma  haematobium^  occurs  not  rarely  in 
the  blood-vessels  of  the  bladder,  and  it  may  give  rise  to  severe 
inflammation,  ulceration,  and  hemorrhage  from  the  mucous  mem- 
brane. The  disease  can  be  diagnosed  from  the  presence  of  distoma- 
ova  in  the  urinary  sediment,  and  these  will  be  recognized  from 
their  oval  shape  and  the  lateral  process.  If  the  bladder  and  the 
intestine  are  adherent  and  in  free  communication,  ascarides  may 
at  times  gain  entrance  into  the  bladder,  and  can  sometimes  be 
removed  from  the  urethra  with  the  fingers. 

Vegetable  parasites,  particularly  bacteria,  are,  as  has  been  men- 
tioned, of  great  significance  in  connection  with  decomposition  of 
urine  and  inflammation  of  the  bladder.  Fragments  of  leptothrix 
have  been  found  in  saccharine  nrine.  At  times  special  sarcincB 
have  been  found  in  the  urine.  These  are  somewhat  smaller  than 
the  sarcinse  of  the  stomach,  but  similar  in  their  quadrangular 
shape  and  in  their  arrangement  in  groups  of  four  or  more.  At 
times  the  sarcinse  form  a  considerable  sediment.  They  occur  in 
alkaline  and  in  acid  urine,  and  give  rise  to  no  particular  symptoms. 
Some  patients  suffer  from  bacteriuria,  their  urine  containing  bac- 
teria at  the  time  of  evacuation,  presenting  a  light-yellow  and  turbid 
appearance,  and  being  characterized  by  a  stale  odor  suggestive  of 
meat-broth.  Symptoms  are  usually  wanting.  The  condition  is 
often  obstinate.  The  administration  of  salol  (1.0 — 15  grains — 1 
powder  every  two  hours)  may  be  recommended. 

FOREIGN  BODIES  IN  THE  URINARY  BLADDER. 

Foreign  bodies  may  be  introduced  into  the  bladder  from  without 
or  find  their  way  into  the  viscus  from  adjacent  organs.     Thus,  in 
^  Schistosoma  hrematobium. — A.  A.  E. 


458  GENITO-URINARY  ORGANS 

a  case  of  a  vesico-iutestinal  fistula  striated  muscular  fibers,  vege- 
table cells,  and  other  articles  of  food  have  been  found  in  the  urinary 
sediment.  At  times  flatus  escapes  from  the  bladder.  Occasion- 
ally gall-stones  are  present  in  the  urinary  bladder,  and  require 
removal  by  means  of  cystotomy,  having  made  their  way  into  the 
bladder  through  the  biliary  passages  or  the  intestine.  Hair  has 
also  been  observed  in  the  urine — pilhnictio — when  communication 
has  been  established  between  the  bladder  and  a  dermoid  or  an 
ovarian  cvst.  Even  bits  of  cartilage  and  of  bone  and  teeth  have 
been  found  in  the  urine  under  such  circumstances. 


NEUROSES  OF  THE  URINARY  BLADDER. 

NOCTURNAL  ENURESIS. 

Symptoms  and  Diagnosis. — Xocturnal  enuresis  consists  in 
unconscious  evacuation  of  the  urine  into  the  bed  during  profound 
sleep,  and  generally  in  the  first  two  hours,  with  the  discovery  only 
in  the  morning  on  awakening,  from  the  wet  body-linen  and  bed- 
linen,  of  what  has  taken  place  during  the  night.  Some  patients 
dream  of  standing  before  a  trench  or  a  pool  of  water  and  of 
having  been  commanded  to  pass  urine  ;  they  obey,  awake  from  the 
dream,  and  become  conscious  of  having  passed  urine  into  the  bed. 
In  some  cases  the  occurrence  takes  place  only  at  long  intervals, 
and  particularly  when  considerable  fluid  has  been  ingested  at  night 
and  the  evening  meal  has  been  taken  late.  Other  patients,  how- 
ever, wet  the  bed  almost  nightly.  The  patients  often  present  a 
pallid  appearance  and  an  excitable  nervous  manner.  In  the  majority 
of  cases  the  disorder  is  curable.  Generally  it  disappears  at  the 
latest  at  about  the  twelfth  year  of  life,  and  only  in  the  small 
minority  does  it  persist  throughout  life.  Under  the  conditions  last 
named  nocturnal  may  be  complicated  by  diurnal  enuresis,  so  that 
the  clothing  is  wet  even  during  the  day  and  in  the  waking  state, 
particularly  on  laughing,  coughing,  or  making  expulsive  effort. 
This  disorder  exerts  an  unfavorable  influence  particularly  upon  the 
mental  state  of  the  patient,  who  avoids  others  and  gradually  with- 
draws from  human  intercourse,  becomes  hypochondriacal,  and 
sometimes  commits  suicide. 

Htiology. — Xocturnal  enuresis  is  a  disease  of  childhood,  and 
if  it  occur,  contrary  to  rule,  in  an  adult,  it  is  indicative  of  pro- 
found nervous  disease  (cerebral  softening,  general  paralysis  of  the 
insane).  At  times  the  disorder  is  the  result  of  defective  education. 
It  should  be  borne  in  mind  that  nocturnal  enuresis  is  a  natural 
condition  in  earliest  childhood,  and  that  it  is  corrected  by  training, 
particularlv  bv  regularly  waking  the  child  from  sleep  and  insist- 
ing upon  evacuation  of  the  bladder.  If  the  guardian  is  indifferent 
or  careless,  the  child  may  readily  become  confirmed  in  the  habit 


NEUROSES  OF  THE   URINARY  BLADDER  459 

of  nocturnal  enuresis.  In  some  cases  indolence  and  convenience 
are  responsible  for  nocturnal  enuresis ;  the  child  is  awakened  from 
sleep  by  a  desire  to  pass  urine,  but  is  disinclined  to  leave  its  warm 
bed  for  the  purpose,  and  endeavors  to  suppress  the  act  till  morn- 
ing, and  is  overtaken  during  sleep  by  the  discharge  of  urine.  An 
inappropriate  evening  meal  also  may  give  rise  to  nocturnal  enuresis, 
especially  if  taken  too  late  or  in  too  large  an  amount,  or  if  it  con- 
tain too  much  liquid,  particularly  beer.  I  have  observed  nocturnal 
enuresis  in  a  number  of  instances  after  indulgence  in  considerable 
amounts  of  fruit.  It  is  noteworthy  that  diabetes  mellitus  and  con- 
tracted kidney  in  children  are  at  times  first  disclosed  by  nocturnal 
incontinence  of  urine,  obviously  in  consequence  of  over-distention 
of  the  bladder  with  urine.  At  times  nocturnal  enuresis  occurs  as 
a  result  of  reflex  irritation,  as,  for  instance,  from  the  presence 
of  intestinal  worms,  vesical  calculi,  phimosis,  villous  hyperplasia 
of  the  urethra,  and  adenoid  vegetations  in  the  bladder.  Without 
doubt,  central  nervous  influences  are  at  times  operative.  It  has 
been  observed  that  the  children  of  epileptics  not  rarely  suffer  from 
nocturnal  enuresis.  The  condition  has  also  been  observed  on  a 
large  scale  in  foundling  asylums,  in  consequence  of  imitation. 
Girls  are  believed  to  suffer  less  commonly  than  boys  on  account 
of  the  greater  capacity  of  the  female  bladder. 

Prognosis. — As  a  rule,  nocturnal  enuresis  is  a  curable  dis- 
order, and  never  dangerous  to  life,  so  that  the  prognosis  is  not 
unfavorable. 

Treatment. — In  every  case  of  nocturnal  enuresis  the  treat- 
ment should  be  beguu  by  regulation  of  the  diet  and  by  training. 
The  patients  should  receive  their  evening  meal  not  less  than  two 
hours  before  going  to  bed,  and  much  liquid,  potatoes,  and  heavy 
articles  of  food  in  general  should  be  avoided.  The  children 
should  sleep  upon  a  firm  mattress,  under  a  light  covering,  and 
should  lie  upon  the  side,  because  nocturnal  incontinence  of  urine 
occurs  with  particular  ease  and  frequency  in  the  recumbent  pos- 
ture. It  is  important  that  the  pelvis  be  elevated,  and  this  may  be 
accomplished  by  raising  the  foot  of  the  bed.  At  ten,  twelve,  and 
three  o'clock  at  night  the  child  should  be  regularly  awakened  from 
sleep  and  made  to  pass  urine,  and  this  rule  should  not  be  aban- 
doned until  the  nocturnal  enuresis  has  remained  permanently  in 
abeyance.  In  addition,  causative  conditions  should  be  relieved — 
causal  therapy.  Intestinal  worms  should  be  expelled,  phimosis  and 
villous  growths  of  the  urethra  should  be  removed,  and  also  hyper- 
plasias in  the  nose.  For  anemic  persons  iron  should  be  prescribed ;  for 
nervous  patients,  nervines,  cold  frictions,  and  the  like.  There  have 
been  recommended,  further,  narcotics,  tincture  of  cantharides,  anti- 
pyrin,  vesicatories  to  the  sacrum,  the  electric  current,  massage,  dila- 
tation of  the  urethra  with  bougies,  cauterization  of  the  neck  of  the 
bladder,  introduction  of  a  cold  sound  {psychrophore),  compresses  for 


460  GEXITO-UmXARY  ORGANS 

the  urethra,  closure  of  the  urethra  and  the  preputial  orifice  with 
collodion  at  night,  in  order  that  the  patient  shall  be  awakened 
from  sleep  when  the  evacuation  of  urine  begins.  In  one  case 
speedy  success  Mas  obtained  l)y  means  of  hypnosis  and  suggestion. 

HYPERESTHESIA  OF  THE  URINARY  BLADDER. 

Btiology. — Hyperesthesia  of  the  urinary  bladder  occurs 
principally  in  hysterical,  hypochondriacal,  or  nervous  individuals, 
in  whom  the  disorder  is  often  due  to  mental  over-exertion, 
alcoholic  and  venereal  excesses,  excessive  indulgence  in  tobacco, 
masturbation,  and  the  like. 

Symptoms  and  Diagnosis. — The  patients  complain  of  in- 
tense vesical  tenesmus,  which  is  appreciated  when  the  bladder 
contains  only  a  small  amount  of  urine.  This  tenesmus  must  be 
promptly  responded  to  in  order  to  avoid  severe  pain,  or  suppress- 
ion of  urine  if  the  delay  be  too  protracted.  Some  patients  with- 
draw from  human  society  and  prefer  to  be  alone,  because  they  are 
free  from  vesical  tenesmus  for  scarcely  half  an  hour.  The  urine 
is  frequently  unaltered,  although  at  times  it  is  highly  acid. 

Prognosis  and  Treatment. — The  prognosis  is  not  unfavor- 
able if  the  clinician  is  capalile  of  exerting  a  favorable  mental  in- 
fluence upon  the  patient  through  his  personality.  The  patient 
should,  in  the  first  place,  be  assured  that  the  disorder  is  a  purely 
nervous  one,  without  anatomic  alteration  ;  and  he  should  be  ad- 
vised to  take  little  liquid,  and  if  possible  to  avoid  alcoholics  en- 
tirelv,  and  should  be  urged  not  to  respond  to  the  desire  for  mic- 
turition at  once,  but  gradually  to  make  the  intervals  between  evac- 
uation longer  and  longer.  In  addition,  the  primary  disorder  should 
receive  the  usual  treatment. 

SPASM  OF  THE  URINARY  BLADDER  (CYSTOSPASM). 

Htiology. — Spasm  of  the  muscular  coat  of  the  urinary  blad- 
der may  result  from  anatomic  alterations  (disease  of  the  bladder, 
the  spinal  cord,  or  the  brain),  or  it  may  be  a  purely  nervous  dis- 
turbance. Only  the  latter  will  be  considered  in  the  following 
description.  The  condition  occurs  most  commonly  in  connection 
with  hysteria,  hypochondriasis,  and  neurasthenia.  Masturbators  at 
times  sutler  from  spasm  of  the  urinary  bladder.  Occasionally  the 
disorder  arises  as  a  result  of  reflex  irritation,  as,  for  instance,  in 
consequence  of  disease  of  the  uterus  or  the  ovaries,  the  presence 
of  worms  in  the  intestine,  etc.  At  times  it  occui's  after  the  inges- 
tion of  voung  wine  or  beer,  or  of  asparagus. 

Symptoms  and  Diagnosis. — Spasm  of  the  muscular  coat  of 
the  bladder  may  involve  the  detrusor  or  the  sjihincter,  or  both 
muscular  structures  together.    Spasm  of  the  detrusor  of  the  bladder 


NEUROSES  OF  THE  URINARY  BLADDER  461 

is  manifested  by  abnormal  desire  for  micturition,  which  may  ap- 
pear even  after  the  accumulation  of  only  a  small  amount  of  urine 
in  the  viscus.  The  disorder  may  readily  be  mistaken  for  hyper- 
esthesia of  the  bladder ;  but  the  latter  is  a  permanent  condition, 
while  spasmodic  states  of  the  detrusor  occur  only  periodically, 
and  urinary  difficulties  are  wanting  in  the  intervals.  Spasm  of  the 
sphincter  of  the  bladder  is  attended  with  disturbances  in  evacua- 
tion of  the  urine.  In  spite  of  existing  tenesmus,  either  the  urine 
is  voided  drop  by  drop — spastic  dysuria — or  there  is  complete  re- 
tention of  urine.  If  a  catheter  be  introduced  into  the  bladder,  it 
Avill  encounter  resistance  at  the  orifice  of  the  viscus  before  it  can 
enter  its  cavity.  The  patients  complain  of  intense  pain  in  mic- 
turition, and  which  not  rarely  radiates  to  remote  parts  (anus,  testi- 
cle, glans  penis).  Simultaneous  spasm  of  the  detrusor  and  the 
sphincter  of  the  bladder  causes  abnormally  increased  desire  for  mic- 
turition, and  obstruction  and  pain  in  the  evacuation  of  urine.  The 
former  is  due  to  spasm  of  the  detrusor,  the  latter  to  that  of  the 
sphincter.  The  pains  are  frequently  so  severe  that  the  patients 
become  pale,  appear  bathed  in  perspiration,  and  may  even  faint. 
Nervous  spasm  of  the  bladder  is  distinguished  from  spasm  of  the 
bladder  dependent  upon  anatomic  alterations  by  the  unchanged 
condition  of  the  urine,  and  the  absence  of  demonstrable  lesions  in 
the  bladder  and  other  organs. 

Prognosis  and  Treatment. — Spasm  of  the  bladder  is  an  an- 
noying disorder  rather  than  dangerous  to  life.  A  warm  bath  (30°  R. 
— 37.5°  C. — 99.5°  F.)  should  be  prescribed,  and  the  patient  urged 
to  pass  water  in  the  bath.  In  addition,  hot  cataplasms  should  be 
applied  over  the  bladder,  and  morphin  should  be  injected  subcu- 
taneously  or  employed  in  suppositories.  In  order  to  prevent 
recurrence  of  the  spasm  it  will  be  necessary  to  adopt  causal  treat- 
ment and  relieve  the  underlying  disease. 

PARALYSIS  OF  THE  BLADDER   (CYSTOPLEGIA). 

!^tiology. — Paralysis  of  the  bladder  is  a  frequent  symptom 
of  many  diseases  of  the  spinal  cord,  as,  for  instance,  myelitis,  trans- 
verse myelitis,  tabes  dorsalis,  multiple  sclerosis,  and  spinal  con- 
cussion. Diseases  of  the  brain  (softening)  also  are  not  rarely 
attended  with  paralysis  of  the  bladder.  The  paralysis  of  the 
bladder  resulting  in  connection  with  opium-poisoning  may  be 
designated  toxic.  At  times  paralysis  of  the  bladder  develops  in 
the  sequence  of  excessive  distention  of  the  viscus.  Such  a  condition 
may  occur  in  comatose  persons,  who  are  unconscious  of  the  stimulus 
to  evacuate  the  bladder,  so  that  the  organ  may  become  filled 
with  a  large  amount  of  urine,  as,  for  instance,  in  cases  of  typhoid 
fever,  meningitis,  and  the  like.  Persons  also  whose  occupation 
renders  it  difficult  to  respond  promptly  to  the  desire  for  micturi- 


462  GENITO-URINARY  ORGANS 

tion  (speakers,  teachers,  actors,  officers)  may  acquire  paralysis  of 
the  bladder  as  the  result  of  frequent  over-distention.  Cystoplegia 
occurs  not  rarely  in  persons  suffering  from  stricture  of  the  urethra 
or  prostatic  hypertrophy,  because  also  both  of  these  conditions 
give  rise  to  distention  of  the  bladder.  At  times  paralysis  of  the 
bladder  is  dependent  upon  diseases  of  the  viscus,  as,  for  instance, 
inflammation  or  carcinoma.  It  may  occur  as  a  purely  nervous  dis- 
order in  hysterical,  hypochondriacal,  and  nervous  persons.  It 
develops  at  times  in  association  with  debilitated  states  of  the  body, 
as,  for  instance,  after  onanism  and  senile  marasmus. 

Symptoms  and  Diagnosis. — In  the  same  way  as  with 
spasm  of  the  bladder,  paralysis  of  the  bladder  at  times  involves 
the  detrusor,  at  otlier  times  the  sphincter,  or  at  still  other  times 
both  muscles  together.  Paralysis  of  the  detrusor  of  the  bladder 
is  attended  with  difficulty  in  the  evacuation  of  urine.  The  patient 
must  make  strong  expulsive  effiDrts  in  order  to  expel  the  urine, 
which  is  discharged  in  a  less  powerful  stream  than  normally. 
The  greater  the  degree  of  paralysis,  the  more  nearly  does  the 
evacuation  approach  gradual  dribbling.  The  bladder  at  times 
becomes  so  greatly  filled  with  urine  that  it  may  rise  to  the  level 
of  the  umbilicus,  and  even  above,  and  the  resulting  excessive 
stretching  of  the  detrusor  is  well  adapted  to  augment  the  paralysis. 
Eventually  the  power  of  voluntary  evacuation  of  the  urine  is  lost, 
and  the  patient  is  condemned  to  systematic  resort  to  the  use  of  the 
catheter.  Paralysis  of  the  sphincter  of  the  bladder  is  attended  with 
dribbling  of  urine — incontinence — which  often  is  at  first  manifested 
by  the  escape  readily  of  urine  into  the  clothing  on  laughing, 
coughing,  or  making  expulsive  effi3rts.  Xot  rarely  bacteria  gain 
access  to  the  bladder  when  the  orifice  of  the  viscus  is  open,  with 
decomposition  of  the  urine  and  inflammation  of  the  bladder. 
Simultaneous  jxtralysis  of  the  detrusor  and  the  sphincter  of  the  blad- 
der gives  rise  to  a  combination  of  the  two  groups  of  symptoms 
described.  The  urine  escapes  involuntarily  from  the  bladder 
until  its  level  falls  just  below  the  vesical  orifice  of  the  urethra. 
If  a  catheter  be  introduced  into  the  bladder  immediately  after 
the  evacuation  of  urine,  additional  urine  will  be  evacuated  which 
had  remained  at  the  base  of  the  bladder,  and  is  therefore  designated 
residual  urine.  Paralysis  of  the  muscular  coat  of  the  bladder  is 
distinguished  from  spasm  of  the  musculature  of  the  bladder  par- 
ticularly by  the  absence  of  pain.  The  duration  of  p>ttr(ilysis  of  the 
bladder  depends  upon  the  causative  factors  in  the  individual  case. 

Prognosis. — Whether  paralysis  of  the  liladder  is  curable  or 
not  depends  mainly  upon  the  causative  factors.  If  these  be 
incurable,  the  principal  danger  consists  in  the  readiness  with  which 
decomposition  of  the  urine  takes  place  and  the  frequently  com- 
plicating inflammation  of  the  bladder,  and  which  in  turn  may 
give  rise  to  pyelonephritis  and  urinary  septicemia. 


IMPOTENCE  IX  THE  MALE  463 

Treatment. — In  the  presence  of  paralysis  of  the  bladder 
attention  should  be  given  to  systematic  evacuation  of  the  viscus. 
At  times  this  end  can  be  attained  by  pressure  upon  the  bladder 
through  the  abdominal  wall ;  otherwise  resort  must  be  had  to  the 
introduction  of  a  catheter,  which  naturally  must  be  carefully 
sterilized.  Artificial  evacuation  of  the  urine  should  be  practised 
thrice  daily.  lu  order  to  strengthen  the  muscular  coat  of  the  blad- 
der cold  frictions  should  be  applied  over  the  bladder,  subcutaneous 
injections  of  strychnin  or  of  ergotin  made,  and  the  galvanic  or  the 
faradic  current  employed.  In  addition,  careful  attention '  should 
be  given  to  the  treatment  of  the  causative  conditions — causal 
therapy. 


IV.   DISEASES  OF  THE  MALE   SEXUAL  ORGANS. 


IMPOTENCE  IN  THE  MALE. 

Ktiology. — Inability  to  effect  coitus  successfully  is  designated 
impotence  in  the  male.  At  times  the  condition  is  dependent  in  a 
purely  mechanical  manner  upon  diseases  of  the  penis,  which  prevent 
the  introduction  of  the  male  organ  into  the  vagina.  The  penis 
may  be  unduly  short,  or  it  may  be  rendered  so  from  the  presence 
of  marked  hydrocele  or  of  scrotal  hernia.  Angular  distortion  of 
the  penis  in  consequence  of  cicatrices  or  new-growths  may  cause 
impotence.  Diseases  of  the  testicles  may  give  rise  to  impotence  if 
the  secretion  of  seminal  fluid  is  abolished,  for,  as  a  rule,  erection 
takes  place  only  when  the  testicles  secrete  semen.  At  times  im- 
potence in  the  male  results  from  wasting  discharges  and  exhaus- 
tion, and  develops  in  the  sequence  of  severe  diseases,  such  as  con- 
tracted kidney,  diabetes  mellitus,  onanism,  and  venereal  excesses. 
Toxic  impotence  may  occur  as  a  result  of  tlie  protracted  use  of 
potassium  bromid,  camphor,  lupulin,  arsenic,  salicylic  acid,  and 
morphin.  At  times  impotence  in  the  male  is  caused  by  nervous 
influences.  Frequently  it  occurs  in  the  course  of  tabes  dorsalis. 
Xeurasthenia  also  is  not  rarely  attended  with  impotence.  Psychic 
impotence  is  particularly  to  be  mentioned.  This  results  from  a 
fear  on  the  part  of  the  patient  that  he  is  not  potent,  and  this  para- 
lyzing dread  either  prevents  entirely  erection  of  the  penis  or  per- 
mits but  transient  erection,  or  there  occur  premature  discharge  of 
semen  and  rapid  flaccidity  of  the  penis.  Psychic  impotence  occurs 
at  times  in  chaste  persons,  particularly  on  the  first  attempts  at 
sexual  intercourse.  It  occurs  also  in  masturbators,  in  whom  a 
guilty  conscience  exerts  a  paralyzing  influence  as  soon  as  an 
attempt  at  normal  sexual  intercourse  is  made.     Also,  the  dissolute 


464  GENITO-URINARY  ORGANS 

habitue  of  the  brothel  is  at  times  attacked  with  psychic  impotence 
in  sexual  intercourse  with  his  wife.  Psychic  impotence  may  be 
manifested  t)nly  in  sexual  relations  with  certain  women.  Some  men 
are  capable  of  overcoming  this  by  certain  devices  which  are  mostly 
repulsive  to  a  healthy  mind.  Psychic  impotence  particularly  has  an 
injurious  influence  upon  the  mental  state,  and  often  induces  suicide. 

Impotence  in  the  male  may  be  temporary  or  permanent,  accord- 
ingly as  the  causative  factors  are  curable  or  irremediable. 

The  prognosis  and  the  treatment  also  depend  upon  the 
nature  of  the  cause.  In  the  presence  of  neurasthenia,  in  addition 
to  nervines,  courses  of  treatment  with  cold  water,  in  the  mountains 
or  at  the  seaside,  will  be  necessary.  In  cases  of  psychic  impotence 
the  patient  should  by  intelligent  encouragement  be  imbued  with 
confidence  in  his  poteuce.  Too  frequent  sexual  intercourse  and 
attempts  at  intercourse  during  alcoholic  intoxication  should  par- 
ticularlv  be  avoided.  Under  such  conditions  also  cold  sponging  of 
the  hypogastrium  and  a  sojourn  in  the  mountains  or  at  the  seaside 
are  often  to  be  recommended.  At  times  good  results  are  secured 
from  hypnosis  and  suggestion.  Upon  the  latter  probably  depend 
the  favorable  effects  reported  from  the  employment  of  tablets  of 
testicular  tissue  and  injections  of  testicular  fluid  or  of  sperm. 
Applications  of  the  galvanic  and  of  the  faradic  current  to  the 
lumbar  spine  and  to  the  sexual  organs  have  also  been  made. 

STERILITY  EST  THE  MALE, 

Sterility  in  the  male  is  present  if  in  spite  of  natural  methods 
of  coitus  no  seminal  fluid  is  discharged  into  the  vagina  of  the 
woman — so-called  aspermatism  ;  or  if  the  seminal  fluid  introduced 
does  not  contain  fructifying  spermatozoids — azoospermia. 

Aspermatism  is  most  commonly  due  to  obstruction  of  the  semi- 
nal ducts  ;  less  commonly  it  is  caused  by  nervous  disturbances. 
Aspermatism  is  often  dependent  upon  stricture  of  the  urethra  in 
consequence  of  chronic  gonorrhea.  Disease  of  the  prostate  gland 
also  not  rarely  causes  aspermatism,  as  the  enlarged  gland  may 
compress  the  urethra  and  thereby  diminish  its  lumen,  or  as  a  result 
of  contracting  changes  may  give  rise  to  such  a  deflection  that  the 
semen  when  ejaculated  will  not  escape  anteriorly,  but  posteriorly 
into  the  bladder.  Disease  of  the  seminal  I'csicles  may  cause  asper- 
matism by  exerting  pressure  upon  and  diminishing  the  lumen  of 
the  ejaculatory  ducts.  At  times  phimosis  is  responsible  for  asper- 
matism if  the  urethra  is,  as  a  result,  materially  constricted.  In- 
juries to  the  j)erineum  are  also  capable  of  causing  aspermatism 
through  compression  of  the  ejaculatory  ducts.  Occasionally  the 
condition  has  been  observed  after  operations  for  stone,  if  the 
ejaculatory  ducts  have  been  cut  by. the  surgeon's  knife. 

Psychic  aspermatism  occurs  principally  in  neurasthenic  indi- 


INVOLUNTARY  DISCHARGE  OF  SEMINAL  FLUID       465 

viduals ;  coitus  can  be  effecteil  without  difficulty,  but  ejaculation 
may  not  take  place  or  onlv  in  intercourse  with  certain  women,  but 
not  with  others.  This  form  of  aspermatism  occurs  especially  in 
masturbators  and  in  men  who  have  engaged  excessively  in  illegit- 
imate sexual  intercourse.  Under  such  circumstances  it  may  happen 
that  ejaculation  of  seminal  fluid  fails  to  take  place,  especially  in 
sexual  intercourse  with  the  wife.  A  variety  of"  jjhysiologic  asper- 
matism occurs  in  healthy  men  who  indulge  in  sexual  intercourse 
at  too  short  intervals. 

Aspermatism  is  readily  recognizable  from  the  fact  that  in 
sexual  intercourse  ejaculation  of  seminal  fluid  does  not  take  place 
at  all,  or  occurs  only  after  the  penis  has  become  flaccid  and  has 
been  withdrawn  from  the  vagina.  Should  an  ejaculation  have 
taken  place,  but  into  the  bladder,  turbid  urine  containing  many 
spermatozoids  will  be  evacuated  after  the  act  of  coitus. 

The  duration  and  the  prognosis,  as  well  as  the  treatment  of 
aspermatism  vary  in  accordance  with  the  causative  factors.  In 
cases  of  psychic  aspermatism  an  endeavor  should  be  made  to  im- 
prove the  general  condition,  while  the  patient  should  be  encour- 
aged with  assurance,  nervines  be  administered,  courses  of  treat- 
ment with  cold  water,  in  the  mountains  and  at  the  seaside,  be 
pursued,  and  applications  of  electricity  be  made. 

Azoospermia  is  characterized  by  an  absence  of  the  secretion  of 
the  testicles,  and  therefore  of  fructifying  spermatozoids,  although 
in  the  sexual  act  secretion  is  discharged  from  the  seminal  vesicles 
and  the  prostate  gland.  The  condition  can  be  readily  recognized 
on  microscopic  examination.  The  ejaculated  fluid  possesses  the 
so-called  seminal  or  spermatic  odor,  because  this  is  due  not  to  the 
secretion  of  the  testicles — the  true  seminal  fluid — but  to  that  of 
the  prostate  gland.  Azoospermia  is  a  most  common  disorder. 
Most  sterile  marriages  arc  dependent  upon  azoospermia,  and  not 
upon  the  often  insignificant  displacements  and  other  abnormalities 
of  the  unoffending  wife.  Gonorrheal  urethritis  is  responsible  for 
azoospermia  with  especial  frequency  if,  in  conjunction  with  gonor- 
rhea, bilateral  orchitis  or  inflammation  of  the  vasa  deferentia  de- 
velops, preventing  the  entrance  of  seminal  fluid  into  the  seminal 
vesicles  and  ejaculatory  ducts.    The  condition  is  generally  incurable. 

Spermatozoids  will  naturally  be  absent  from  the  secretion  of  the  gener- 
ative organs  if  the  tissues  of  the  testicles  are  seriously  diseased  and  the 
normal  function  of  the  latter  is  suppressed.  Such  conditions  are  generally 
attended  with  impotence,  and  are  therefore  not  included  in  azoospermia. 

INVOLUNTARY     DISCHARGE    OF     SEMINAL    FLUID 
(SPERMATORRHEA), 

Spermatorrhea  consists  in  the  discharge  of  secretion  from  the 
generative  glands   independently  of  the  sexual  act.     The  ejacu- 

30 


466  GENITO- URINARY  ORGANS 

lated  fluid  may  be  derived  i'vom  the  testicles,  the  prostate  gland, 
tlie  seminal  vesicles,  the  glands  of  Littre  or  those  of  Cowper, 

TRUE  SPERMATORRHEA. 

Symptoms  and  Diagnosis. — True  .sjjernmtorrhea  is  attended 
with  the  discharge  from  the  uretlira  of  testicular  secretion,  which 
is  readily  recognized  on  microscopic  examination  from  the  pres- 
ence of  numerous  spermatozoids.  Occasionally  these  are  imper- 
fectly developed,  with  a  slender  filament  attached  to  the  head. 
Their  want  of  motility  also  is  at  times  conspicuous.  At  times 
so-called  seminal  cells — large  multinucleated  cells — are  present. 
If  seminal  fluid  inconsiderable  amount  is  admixed  with  the  urine, 
the  latter  acquires  a  milky,  fat-like  appearance — lipuria — which 
disappears  when  the  urine  is  agitated  with  ether,  preferably  after 
addition  of  potassium  hydroxid. 

Involuntary  discharge  of  seminal  fluid  occurs  at  night  from 
time  to  time  in  every  healthy  man — nocturnal  pollution.  Under 
such  conditions  lascivious  dreams  generally  occur,  and  with  cus- 
tomary erection  of  the  penis  and  a  pleasurable  sensation  a  discharge 
of  seminal  fluid  takes  place,  and,  as  a  rule,  causes  awakening. 
The  occurrence  is  usually  followed  by  a  sense  of  great  freshness 
on  the  following  night.  Such  pollutions  are  repeated  in  difi'erent 
men  at  varying  intervals,  in  some  within  from  4  to  8  weeks,  in 
others  within  from  4  to  8  days,  in  accordance  with  the  tempera- 
ment, the  constitution,  and  the  mode  of  life  of  the  individual. 

Abnormal  nocturnal  pollutions  are  characterized  by  the  reciu'- 
rence  of  seminal  emissions  during  the  same  night  or  on  several 
successive  nights,  by  incomplete  erection  of  the  penis  or  its  total 
absence,  by  the  absence  of  voluptuous  dreams,  by  failure  to  be 
awakened  by  the  discharge,  and  the  failure  of  the  latter  to  be 
followed  by  a  sense  of  freshness,  but  by  one  of  exhaustion,  with 
the  association  of  headache,  vertigo,  pal])itation  of  the  heart,  a 
sense  of  constriction  and  of  weakness  in  the  legs. 

A  more  profound  degree  of  the  disorder  is  attended  with  semi- 
nal discharges  also  during  the  day  and  the  waking  hours — diurnal 
pollutions.  These  may  occur  upon  any  sexual  excitement,  how- 
over  slight,  as,  for  instance,  in  reading  obscene  books,  in  looking 
at  voluptuous  pictures,  in  contact  with  women,  and  even  in  looking 
at  women  or  in  thinking  of  sexual  matters.  This  condition  may 
eventually  lead  to_  permanent  spermatorrhea,  which  is,  however,  a 
rare  disorder.  The  latter  is  attended  with  the  constant  discharge 
of  seminal  fluid  from  tlie  urethra  and  its  accumulation  in  the  ]>re- 
putial  sac  without  any  pleasural:)le  sensation.  Often  this  condi- 
tion is  preceded  for  a  time  by  spermafnrrltea  attending  micturition 
and  defecation,  the  discharge  of  seminal  fluid  taking  place  only  in 
association  with  those  acts. 

Spermatorrhea  exerts  a  most  injurious  psychic  influence  upon 


INVOLUNTARY  DISCHARGE  OF  SEMINAL  FLUID        467 

the  patient,  and  the  more  so  as  it  is  frequently  observed  in  persons 
with  an  abnormally  irritable  and  excited  nervous  system.  The 
patients  are  worried  particularly  by  the  thought  that  they  can 
never  again  be  potent,  and  in  many  cases  there  is  present  in  addi- 
tion the  consciousness  that  the  patient  is  himself  responsible  for 
the  disorder  as  a  result  of  sexual  excesses  and  masturbation.  The 
great  fear  of  a  gloomy  future  on  the  one  hand,  and  the  want  of 
courage  to  renounce  sexual  abuse  forever  on  the  other  hand,  are 
often  remarkable.  Persons  with  spermatorrhea  may  for  a  long 
time  preserve  a  healthy  and  even  a  vigorous  appearance ;  but,  as 
a  rule,  they  gradually  grow  paler  and  more  emaciated,  are  troubled 
with  sleeplessness  and  increasing  exhaustion,  become  more  and  more 
neurasthenic,  and  some  reach  the  insane  asylum  or  commit  suicide. 

Ktiolog^?-. — Spermatorrhea  is  a  common  sequel  of  sexual  ex- 
cesses, both  natural  and  unnatural — onanism.  At  times  it  occurs 
as  a  result  of  reflex  irritation  in  the  presence  of  gonorrheal  ureth- 
ritis, phimosis,  retained  preputial  sebum,  worms,  hemorrhoids, 
anal  fissure,  and  the  like.  Occasionally  the  disorder  is  dependent 
upon  disease  of  the  central  nervous  system,  as,  for  instance,  tabes 
dorsalis  or  a  transverse  lesion  of  the  spinal  cord.  Spermatorrhea 
occurs  also  at  times  during  epileptic  convulsions.  In  some  cases 
spermatorrhea  is  ijiduced  by  conditions  of  general  debility.  It  may 
therefore  be  observed  in  the  sequence  or  course  of  typhoid  fever, 
pulmonary  tuberculosis,  and  diabetes.  Members  of  families  with 
an  inherited  nervous  temperament  and  persons  who  have  made 
themselves  nervous  by  excessive  mental  activity  or  by  excessive 
indulgence  in  alcohol,  tea,  or  tobacco  are  undeniably  predisposed 
to  spermatorrhea. 

The  prognosis  and  the  treatment  depend  primarily  upon 
the  causative  factors.  Onanism  and  sexual  excesses  are  to  be 
avoided,  and  irritative  conditions  (gonorrhea,  phimosis,  worms, 
etc.)  to  be  relieved.  To  subdue  excessive  sexual  desire,  anaphro- 
disiacs  have  been  recommended  (potassium  bromid — 3.0 — 45  grains 
— at  night  in  a  wine-glassful  of  milk ;  camphor  or  lupulin — 0.3 — 
4i  grains — four  times  daily).  The  mode  of  life  is  imjDortant.  The 
evening  meal  should  be  light,  and  be  taken  three  hours  before  bed- 
time. The  bed  should  consist  of  a  hard  mattress  and  a  light  cover. 
The  patient  should  try  to  sleep  on  his  side,  as  experience  has 
shown  that  pollutions  readily  occur  in  the  dorsal  decubitus.  An 
effort  should  be  made  to  make  a  moral  impression  on  the  patient, 
and  to  invigorate  his  general  condition  by  cold  baths  or  spongings, 
systematic  walks,  and  in  the  summer  by  a  sojourn  in  tlie  moun- 
tains or  at  the  seaside. 

The  treatment  of  spermatorrhea  has  been  largely  undertaken  by  charla- 
tans. As  a  rule,  a  circular  is  first  sent  the  patient  arousing  his  fears,  and 
finally  a  useless  medicinal  remedy  or  some  form  of  apparatus  is  otiered  at 
an  extravagant  price.     Thus,  alarms  have  been  constructed  for  the  purpose 


468  GENITO-URINARY  ORGANS 

of  arousing  the  patient  frona  sleep  on  the  approach  of  an  impending  pollution, 
and  thus  preventing  the  seminal  discharges.  Lallemand,  who  attributed 
spermatorrhea  in  all  cases  to  chronic  inflammation  of  the  caput  gallinaginis 
of  the  urethra,  devised  a  caustic-carrier,  and  made  applications  of  silver 
nitrate  to  the  caput  gallinaginis.  The  application  of  a  cold  bougie  or  y^sy- 
chrophore  has  been  much  practised. 

PROSTATORRHEA. 

Prostatorrhea  is  attended  with  the  discharge  from  the  urethra 
of  turbid,  milky  secretion  possessing  a  spermatic  odor,  and  on 
microscopic  examination  containing  cylindric  epithelium,  lamin- 
ated amyloid  bodies,  round  cells,  and  gi'anules  or  scales  of  yellowish 
pigment.  The  occurrence  of  sperm-crystals  is  especially  charac- 
teristic of  prostatic  secretion.  They  resemble  asthma-crystals,  but 
are  four-sided,  and  not  six-sided,  double  pyramids.  These  crys- 
tals are  precipitated  on  addition  of  a  1  per  cent,  solution  of  ammo- 
nium phosphate  to  prostatic  secretion.  Prostatorrhea  may  occur 
in  conjunction  with  inflammatory  processes  in  the  prostatic  gland, 
which  result  frequently  in  consequence  of  gonorrhea  or  anemia,  but 
also  in  the  aged  as  senile  hypertrophy  of  the  prostate.  The  pros- 
tatic secretion  makes  its  appearance  not  rarely  after  defecation,  at 
times  after  coughing  and  expulsive  efforts,  or  it  is  discharged  exter- 
nallv  if  a  finger  is  introduced  into  the  rectum  and  pressure  is  made 
upon  the  prostate  through  the  anterior  wall  of  the  bowel.  The 
disorder  is  often  the  cause  of  unnecessary  fear  on  the  part  of  the 
patient,  as  the  prostatic  secretion  is  mistaken  for  seminal  fluid,  but 
the  affection  is  wholly  free  from  danger. 

Secretion  from  the  seminal  vesicles  can  be  recognized  from  the  presence  of 
the  bodies  described  by  Lallemand  and  Trousseau,  which  resemble  swollen 
sago-granules  and  consist  of  a  globulin-substance.  The  glands  of  Cowper 
and  of  Littre  in  some  cases  secrete  considerable  fluid  on  erection.  The 
.secretion,  which  contains  round  cells  and  epithelial  cells  in  small  number, 
on  drying  readily  causes  agglutination  of  the  lips  of  the  urethral  meatus. 


V.    DISEASES   OF  THE  ADRENAL   BODIES. 


ADDISON'S  DISEASE. 

Symptoms  and  Diagnosis. — Addison's  disease  is  attended 
with  a  dark  discoloration  of  the  skin  and  the  mucous  membranes 
and  gradual Iv  jirogressive  asthenia.  At  times  the  discoloration 
of  the  skin  and  the  mucous  membranes  is  the  earliest  symjitom, 
while  at  other  times  anorexia,  vomiting,  irregularity  in  movement 
of  the  bowels,  general  malaise,  and  the  like,  have  been  present 
for  .some  time  previously  as  prodromes.  These  prodromal  .symp- 
toms are  perhaps  only  the  results  of  auto-intoxication  dependent 


ADDISON'S  DISEASE  469 

upon  disease  of  the  adrenal  bodies.  The  cutaneous  alterations 
generally  appear  earliest  in  parts  of  the  body  exposed  to  the  light ; 
then  follow  places  subjected  to  pressure,  or  under  normal  condi- 
tions the  seat  of  pigmentation.  Eventually  the  discoloration  in- 
volves the  skin  of  the  entire  body.  The  dark  color  of  the  skin, 
which  often  is  suggestive  of  the  appearance  of  bronze,  has  helped 
to  give  the  disease  the  name  of  hronze-disease.  At  the  commence- 
ment of  the  discoloration  of  the  skin  small,  dark  sjDots  appear ; 
these  soon  increase  in  size,  coalesce  with  adjacent  spots,  and 
then  discolor  the  skin  uniformly  throughout  a  considerable  extent. 
The  first  alterations  are  usually  observed  in  the  face,  which  ac- 
quires a  brownish  hue,  as  if  the  skin  had  been  burned  by  the  rays 
of  the  sun ;  subsequently  the  color  becomes  more  like  that  of 
graphite,  so  that  it  may  be  confounded  by  the  inexperienced 
clinician  with  cyanosis.  The  patient  resembles  a  mulatto.  Also, 
the  hands  and  the  forearms,  in  persons  who  go  barefooted  the 
dorsum  of  the  feet  and  the  legs,  participate  early  in  the  cutaneous 
discoloration.  The  palmar  aspect  of  the  hands  and  the  plantar 
aspect  of  the  feet,  however,  as  well  as  the  nails  of  the  fingers  and 
the  toes,  remain  unaltered,  and  are  often  conspicuous  for  their 
bright  and  pale  appearance.  On  the  trunk  a  dark,  discolored 
cutaneous  girdle  is  observed  to  encircle  the  junction  of  the  abdo- 
men and  the  thorax,  corresponding  to  the  constriction  induced 
by  waist-bands  and  other  articles  of  clothing.  The  nipples,  the 
axillary  cavity,  the  scrotum,  and  the  penis  are  usually  conspicuous 
for  their  dark-brown  or  black  color.  Of  the  mucous  membranes, 
that  of  the  oropharynx  becomes  affected  particularly  early,  and 
especially  upon  the  mucous  membrane  of  the  cheeks  opposite  the 
teeth  a  brownish  or  blackish  oval  or  irregular  area  is  frequently 
found  whose  borders  often  pursue  an  irregular,  serrated  course. 
Now  and  then,  but  on  the  whole  uncommonly,  small  brownish  or 
blackish  spots  are  observed  upon  the  conjunctiva,  which  may 
readily  escape  detection  on  account  of  their  small  size.  In  women 
similar  alterations  occur  upon  the  mucous  membrane  of  the  labia 
minora  and  the  vagina. 

Addison's  disease  is  readily  recognized  from  the  discoloration 
of  the  skin  and  the  mucous  membranes.  Long-continued  employ- 
ment of  silver  nitrate  may  give  rise  to  a  dark  discoloration  of  the 
skin — so-called  argyria  or  argyrosis ;  but  the  fact  of  the  internal 
or  external  employment  of  this  agent  can  be  determined  by  inquiry 
into  the  history.  The  same  statement  is  applicable  to  arsenical 
melanosis ;  that  is,  that  dark  discoloration  of  the  skin  that  appears 
in  some  persons  after  long-continued  use  of  arsenic.  The  color 
of  the  skin  in  cases  of  Addison's  disease  differs  from  that  observed 
in  brunets  and  in  those  who  live  in  the  tropics  in  the  fact  that 
with  the  former  general  symptoms  are  present  besides,  and  these 
will  shortly  be  described.     It  is  noteworthy,  further,  that  in  some 


470  GENITO-URINARY  ORGANS 

healthy  persuns  dark  spots  like  those  of  Addison's  disease  occur 
upon  the  mucous  membrane  of  the  lips  or  the  cheeks.  Persons 
who  have  been  infested  for  a  long  time  with  body-lice — Pediculi 
vestimentoruia — often  present  a  brownish  or  l)lackish  discoloration 
of  the  skin  in  c(jnsequenee  of  extravasation  of  blood  at  the  points 
of  biting — cutaneous  nigrities — but  the  face  and  the  mucous  mem- 
branes escape.  In  persons  of  uncleanly  habits  the  skin  may 
present  a  brownish  or  blackish  appearance  due  to  dirt :  but  this 
can  readily  be  removed  by  means  of  soap  and  water. 

Constitutional  symptoms  are  generally  not  long  absent.  There 
is  progressive  loss  of  appetite,  with  nausea  and  vomiting  and  pro- 
gressive asthenia.  Often  debilitating  diarrhea  sets  in.  At  times 
complaint  is  made  of  pain  in  one  or  both  renal  regions,  and  this 
often  is  increased  on  pressure.  Also,  pains  in  muscles  and  joints 
occur  frequently.  The  action  of  the  heart  is  generally  accelerated, 
and  the  tension  of  the  pulse  is  greatly  diminished.  The  mental 
state  is  generally  one  of  depression  and  dejection.  At  times  ver- 
tigo, a  sense  of  pressure  in  the  head,  tremor,  convulsions,  and 
paralysis  occur.  As  a  rule,  the  patients  fail  gradually  with  pro- 
gressive asthenia.  In  a  number  of  instances  I  have  observed  the 
rather  sudden  development  of  coma,  followed  by  death,  the  con- 
dition suffficestino;  auto-intoxication.  It  is  noteworthv  that  at 
times  the  constitutional  symptoms  and  the  comatose  condition 
described  may  occur  in  the  absence  of  discoloration  of  the  skin 
and  the  mucous  membranes,  whereas  an  autopsy  may  disclose  only 
disease  of  the  adrenal  bodies,  thus  auto-intoxication  without  bronz- 
ing. The  duration  of  the  disease  extends  at  times  over  more  than 
a  year. 

'  Anatomic  Alterations. — The  dark  discoloration  of  the  skin 
and  the  mucous  membranes  persists  after  death.  On  microscopic 
examination  of  the  skin  brownish  or  blackish  pigment-granules 
are  found  in  the  lowermost  layers  of  cells  of  the  rete  Malpighii. 
Round  and  branched  cells  filled  with  pigment-granules  occur  also 
in  the  cutis.  Of  the  internal  organs,  the  adrenal  bodies  particu- 
larly attract  attention,  being  diseased  in  tlie  majority  of  cases, 
though  not  in  all.  Most  commonly  the  condition  is  one  of  tuber- 
culous-caseous change,  which  in  turn  may  be  primary  or  second- 
ary ;  less  commonly  there  may  be  carcinoma,  amyloid  degeneration, 
gummatous  nodules,  hemorrhage,  chronic  fibrous  inflammation,  or 
even  cchinococcus.  At  times  the  alterations  are  only  unilateral, 
but  in  most  cases  they  are  bilateral.  In  addition  to  the  alter- 
ations in  the  adrenal  bodies,  degeneration  of  ganglion-cells  and 
nerve-fibers  and  connective-tissue  hyperplasia  in  the  solar  plexus 
have  been  observed  ;  and  because  in  some  cases  of  Addison's  dis- 
ease the  adrenal  bodies  have  appeared  unchanged  the  opinion  has 
been  formed  that  the  disorder  is  dependent  upon  disease  of  the 
solar  plexus  of  the  sympathetic  system,  and  that  the  alterations 


ADDISON'S  DISEASE  471 

in  the  adrenal  bodies  are  rather  subordinate.  Naturally,  this  view 
is  not  in  accord  with  the  fact  that  even  expert  observers  have 
found  the  solar  plexus  intact.  There  raaining  organs  exhibit  in 
part  signs  of  emaciation.  In  cases  of  secondary  tuberculosis  of 
the  adrenal  bodies  the  same  condition  has  been  found  in  the  lungs, 
the  kidneys,  the  bones,  and  elsewhere. 

Ktiolog"y. — The  causes  of  Addison's  disease  are  often  un- 
known, and  the  condition  must  then  be  designated  cryptogenetic. 
At  other  times  tuberculosis  or  carcinoma  in  other  organs,  antecedent 
syphilis,  suppuration,  or  other  wasting  discharge,  may  suggest  that 
the  adrenal  bodies  are  the  seat  of  tuberculosis,  carcinoma,  gumma, 
or  amyloid  disease,  with  consequent  development  of  Addison's  dis- 
ease. At  times  the  disorder  is  attributed  to  injuries  in  the  renal 
region,  and  it  is  dependent  upon  hemorrhage.  Generally  adults 
are  attacked  by  the  disease,  which  is  the  more  common  in  men. 

The  pigment  in  the  skin  and  the  mucous  membranes  is  derived  from  the 
transformation  of  hemoglobin,  but  the  reason  for  the  destruction  of  red 
blood-corpuscles  in  Addison's  disease  is  unknown.  It  has  been  thought 
that  in  consequence  of  disease  of  the  adrenal  bodies  certain  substances  are 
retained  in  the  blood  (pyrocatechin  ?  taurocholic  acid  ?),  which  cause  marked 
destruction  of  red  blood-corpuscles.  In  those  cases  in  which  the  adrenal 
bodies  are  found  unaltered  it  would  be  necessary  to  assume  that  the  diseased 
abdominal  sympathetic  nerve  exerted  the  same  influence  upon  the  activity 
of  the  adrenal  bodies  as  if  the  adrenals  themselves  were  diseased.  Where 
the  destruction  of  red  blood-corpuscles  and  where  the  transformation  of  the 
hemoglobin  takes  place,  and  why  the  pigment  is  deposited  precisely  in  the 
skin  and  the  mucous  membranes,  are  all  questions  to  which  at  present  satis- 
factory answers  cannot  be  given. 

Prognosis. — The  prognosis  of  Addison's  disease  is  unfavora- 
ble, as  the  disorder  invariably  terminates  fatally. 

Treatment. — Specific  remedies  for  Addison's  disease  are  not 
known.  Of  late,  organotherapy  has  been  attempted,  and  tablets 
of  adrenal  extract  have  been  administered ;  but  the  reports  as  to 
the  results  are  contradictory  and  still  too  scanty  to  permit  of  a 
final  opinion  in  one  or  the  other  direction.  There  thus  remains 
scarcely  any  but  symptomatic  treatment.  An  endeavor  should  be 
made  particularly  to  maintain,  and  if  possible  to  improve,  the 
general  condition  by  means  of  nutritious  food,  codliver-oil,  and 
preparations  of  iron  or  iodin.  In  the  presence  of  antecedent 
svphilis  the  employment  of  mercurials  and  iodids  would  be  in- 
cluded in  the  causal  therapy. 


PART  V. 
DISEASES  OF  THE  NERVOUS  SYSTEM. 


I.    DISEASES   OF  THE   PERIPHERAL   NERVES. 


PERIPHERAL   PARALYSIS. 

PRELIMINARY  CONSIDERATIONS, 

Peripheral  paralysis  frequently  comes  under  observation  of 
the  practitioner  for  treatment.  Among  the  causative  factors  ex- 
posure to  cold,  traumatism,  toxic  influences,  and  infections  mav  be 
mentioned,  and,  accordingly,  a  distinction  has  been  made  between 
refrigeratory  (rheumatic),  traumatic,  toxic,  and  infectious  periph- 
eral paralysis.  Toxic  and  infectious  influences  exhibit  allied 
relations  with  each  other  in  so  far  as  infectious  paralysis  also  is 
due  to  poisons,  which,  however,  are  of  bacterial  origin  (toxins). 
As  experience  has  shown,  different  nerves  are  involved  in  periph- 
eral paralysis  with  varying  frequency.  The  nearer  the  surface 
and  the  longer  the  superficial  course  of  a  nerve,  the  more  is  it  ex- 
posed particularly  to  the  action  of  cold  and  traumatism,  and  the 
more  frequently  is  it  the  seat  of  paralysis.  Paralysis  of  the  facial 
and  of  the  radial  nerve  is,  therefore,  of  common  occurrence.  In 
cases  of  toxic  paralysis  the  remarkable  and  hitherto  unexplained 
phenomenon  is  observed  that  definite  nerves  are  generally  paral- 
yzed by  certain  poisons.  Thus,  it  is  well  known  that  lead-poison- 
ing peculiarly  gives  rise  to  bilateral  radial  paralysis.  Peripheral 
paralysis  can  be  readily  recognized,  for  the  paralyzed  muscles  are 
incapable  of  contraction  and  exerting  their  functional  activity.  In 
favor  of  the  peripheral  origin  of  a  paralysis  is  the  fact  that  only  a 
few  nerves  and  their  related  muscles  are  involved.  Also,  when 
all  of  the  nerves  and  muscles  of  one  extremity  are  paralyzed  the 
condition  is  generally  due  to  peripheral  causes,  which  often  are 
seated  in  the  nerve-plexus  controlling  the  paralyzed  extremity. 
On  the  other  hand,  paralysis  of  both  upper  and  lower  extremities, 
or  of  all  the  lower  extremities  simultaneously — paraplegia — is  m- 
dicative  of  a  spinal  origin,  and  paralysis  of  the  arm  and  the  leg 

472 


PERIPHERAL  PARALYSIS  473 

upon  one  side  of  the  body — hemiplegia — is  indicative  of  a  cerebral 
origin. 

Great  importance  in  the  diagnosis  and  the  prognosis  of 
peripheral  paralysis  is  attached  to  the  electric  irritability  of  the 
paralyzed  nerves  and  muscles.  If  a  nerve  is  injured  anatomically 
in  only  a  slight  degree,  if  therefore  the  condition  is  one  of  slight 
peripheral  paratysis,  which,  as  experience  has  shown,  generally 
subsides  in  from  two  to  four  weeks,  the  electric  irritability  of  the 
affected  nerves  and  muscles  exhibits  no  alteration  as  compared 
with  the  healthy  side,  and  both  nerves  and  muscles  react  to  the 
faradic  and  the  galvanic  current  with  equal  current-strength  as 
the  corresponding  muscles  and  nerves  upon  the  healthy  side.  A 
peripheral  paralysis  of  moderate  severity  subsides  in  the  course 
of  from  four  to  eight  weeks,  and  can  be  recognized  from  the  pres- 
ence of  partial  degenerative  electric  reaction.  This  is  manifested 
by  the  circumstance  that  for  the  stimulation  of  the  diseased  nerve- 
trunk  by  means  of  the  faradic  or  the  galvanic  current  (so-called 
indirect  stimulation)  considerably  stronger  currents  are  required 
than  for  the  corresponding  nerves  of  the  healthy  side.  On  direct 
stimulation  of  the  paralyzed  muscles  the  irritability  to  the  faradic 
current  will  be  found  diminished,  while  that  to  the  galvanic  cur- 
rent is  increased,  and,  besides,  in  contradistinction  from  healthy 
muscles,  a  considerably  feebler  galvanic;  current  is  required  to  obtain 
anodal  closure-contraction  than  kathodal  closure-contraction.  This 
condition  is  spoken  of  as  a  reversal  of  the  normal  contraction- 
formula,  AnClC  >  KaClC. 

A  severe  peripheral  paralysis  either  requires  from  eight  to 
twelve  weeks,  or  even  more,  for  recovery  to  take  place ;  or  only 
partial  recovery  takes  place,  the  motility  of  only  some  muscles 
being  restored,  while  others  remain  paralyzed  ;  or  no  improvement 
whatever  ensues,  but,  on  the  contrary,  the  paralyzed  muscles 
undergo  progressive  atrophy,  become  permanently  shortened  (con- 
tracture), and  are  periodically  involved  in  involuntary  contraction. 
On  electric  examination  of  a  severe  peripheral  paralysis  total  de- 
generative electric  reaction  will  be  found.  As  compared  with 
partial,  total  degenerative  reaction  is  distinguished  by  the  fact 
that  the  paralyzed  nerve  has  lost  its  irritability  completely  to  both 
faradic  and  galvanic  currents.  The  manifestations  on  direct  irri- 
tation of  the  muscles  by  means  of  the  faradic  or  the  galvanic 
current  agree  with  those  of  partial  degenerative  reaction.  Should 
recovery  from  a  severe  peripheral  paralysis  take  place,  it  is  dis- 
tinctive for  voluntary  muscular  movement  to  occur  earlier  in  the 
paralyzed  parts  than  it  is  possible  to  induce  it  by  electric  stimula- 
tion of  the  previously  paralyzed  nerves.  The  character  of  the 
muscular  contractions  that  take  place  in  cases  of  severe  and 
moderately  severe  paralysis  upon  stimulation  with  the  galvanic 
current  is  further  noteworthy.     The  muscular  contractions  are  not 


474  NERVOUS  SYSTEM 

short  and  liglitning-like,  but  slow  and  protracted,  and  they  re- 
semble per'idaltiG  muscular  iiiovements.  This  phenomenon  is  not 
less  significant  in  the  recognition  of  partial  and  total  degenera- 
tive electric  reaction  than  the  reversal  of  the  contraction-formula. 
In  connection  with  both  partial  and  total  degenerative  electric 
reaction,  not  only  is  the  direct  irritability  of  the  paralyzed  muscles 
to  the  galvanic  current  increased,  but  also  the  mechanical  muscular 
irritability  is  augmented,  so  that  even  gentle  percussion  of  the 
muscles  is  sufficient  to  induce  active  contraction.  In  precisely 
the  same  way  as  with  galvanic  muscular  stimulation,  also  with 
mechanical  irritation,  it  will  be  found  that  the  muscular  contrac- 
tion is  not  lightning-like,  but  slow  and  peristaltic. 

Division  of  nerves  in  animals  has  demonstrated  that  the  manifestations 
of  total  degenerative  electric  reaction  are  dependent  upon  degeneration 
of  the  nerve-fibers  (destruction  of  the  medullary  sheath  and  the  axis- 
cylinder,  multiplication  of  the  nuclei  in  the  nerve-sheath  of  Schwann). 
In  consequence,  the  diseased  nerve  is  incapable  of  transmitting,  and  of 
being  stimulated  by,  the  faradic  and  the  galvanic  current.  The  paralyzed 
muscles  also  undergo  anatomic  alterations.  The  individual  muscle-fibers 
become  smaller,  and  exhibit  multiplication  of  the  nuclei  of  the  sarcolemma 
and  increase  of  the  intermuscular  connective  tissue.  Under  such  conditions 
the  diseased  muscle  loses  its  power  of  responding  with  contraction  to  brief 
stimulation  by  the  faradic  current,  while  the  irritability  to  the  galvanic 
current  is  increased.  The  electric  irritability  of  the  diseased  nerve  can  be 
restored  only  if  the  degenerated  nerve-fiber  is  reformed  or  regenerated. 
The  axis-cylinders  develop  first.  In  this  stage  of  regeneration  the  nerve- 
fibers  are  already  capable  of  conducting  impulses  of  the  will ;  but  they 
become  susceptible  to  electric  stimuli  only  after  the  previously  naked  axis- 
cylinders  are  surrounded  with  a  medullary  sheath. 

The  phenomena  of  degenerative  electric  reaction  are  not  at 
once  present  with  the  onset  of  peripheral  paralysis,  but  develop 
gradually  only  in  the  course  of  the  second  week  of  the  disease, 
as  some  time  is  required  for  the  nerve  and  its  related  muscles  to 
undergo  degenerative  atrophy. 

Degeneration  of  peripheral  nerves  and  muscles  occurs  not  only  in  con- 
nection with  diseases  of  peripheral  nerve-trunks,  but  also  when  the  large 
motor-trophic  gangJion-ceUs  in  the  anterior  horns  of  the  spinal  cord  are  dis- 
eased. Disorders  of  the  latter  variety  are  designated  also  anterior  polio- 
myelitis. Consequently,  degenerative  electric  reaction  is  encountered  also 
in  the  disease  named.  The  ganglion-cell  in  the  anterior  horns  of  the  spinal 
cord,  its  axis-cylinder  process,  and  the  distribution  of  the  latter  in  the 
peripheral  nerve-trunk  to  the  related  muscle  form  a  continuous  whole,  or 
a  neuron.  The  phenomena  of  degenerative  electric  reaction  may  be  so 
interpreted  as  to  indicate  destruction  of  the  spinal-peripheral  neuron  at  its 
central  point  of  origin  or  in  the  course  of  its  peripheral  distribution  :  in 
the  first  instance  a  degeneration  of  the  whole  neuron  resulting,  in  the  latter 
only  of  the  peripheral  portion  beyond  the  focus  of  the  disease.  In  the 
presence  of  disease  of  the  ganglion-cells,  accordingly,  the  phenomena  of 
degenerative  electric  reaction  will  be  present  in  the  entire  peri]ihcral  distri- 
bution of  the  nerve,  and  in  the  presence  of  disease  of  the  peripheral  nerve- 
trunk  itself  only  in  the  distribution  of  that  portion  of  the  nerve  distal  to 
the  situation  of  the  disease-focus. 


PERIPHERAL  PARALYSIS  475 

In  the  treatment  of  peripheral  paralysis  causal  therapy  should 
always  be  considered.  When  exposure  to  cold  has  been  operative 
salicylic  acid  or  sodium  salicylate  may  be  employed  (1.0 — 15 
grains — 1  powder  every  two  hours  until  ringing  in  the  ears 
occurs).  Diaphoretics  (hot  infusions,  pilocarpin  subcutancously) 
and  hot  cataplasms,  applications  of  cotton-wadding,  and  the  like, 
have  also  been  employed.  Antecedent  syphilis  will  require  mer- 
curial inunctions  and  administration  of  potassium  iodid  (5.0  :  200 
— 75  grains  :  6^  fluidounces;  15  c.c. — 1  tablespoonful — thrice 
daily).  Potassium  iodid  also  may  be  employed  in  the  treatment 
of  toxic  paralysis,  for  in  cases  of  lead-poisoning  it  has  been  shown 
that  potassium  iodid  aids  in  the  elimination  of  lead  from  the  body. 
Causal  treatment  occupies  a  conspicuous  place,  fin'ther,  in  all  cases 
of  traumatic  peripheral  paralysis.  If  nerves  are  injured  by  com- 
pression, the  injurious  influence  should  be  removed.  Paralysis  of 
the  nerves  of  the  arms,  for  instance,  develops  at  times  in  con- 
sequence of  pressure  induced  by  improperly  constructed  or  badly 
fitting  crutches,  and  under  such  conditions  these  supports  must  be 
dispensed  with  for  the  time  and  be  properly  adjusted  after  recovery 
has  taken  place ;  or,  after  fractures  of  bone,  nerves  are  sometimes 
surrounded  by  callus,  and  paralysis  results  from  the  pressure 
exerted.  Under  such  conditions  the  only  remedy  consists  in  ex- 
posure of  the  callus  by  operatiou,  its  division  with  a  chisel,  and 
the  setting  free  of  the  imprisoned  nerve.  At  other  times  a  nerve 
has  been  divided  and  paralyzed,  and  remains  paralyzed,  although 
the  cut  extremities  of  the  nerve  have  iniited  by  means  of  a  con- 
nective-tissue cicatrix.  Under  such  conditions  remarkably  success- 
ful results  have  been  at  times  obtained  by  excising  the  connective- 
tissue  cicatrix  and  freshening  the  extremities  of  the  nerve  with 
the  knife,  and  uniting  them  by  means  of  suture. 

SpecijiG  remedies  in  the  treatment  of  peripheral  paralysis  are  as 
yet  unknown.  It  was  formerly  thought  that  the  electric  current 
was  capable  of  accelerating  the  regeneration  of  diseased  and 
degenerated  nerve-fibers,  but  this  is  scarcely  correct.  Electric 
treatment  also  must  be  included  among  symptomatic  measures. 
Also,  in  the  purely  symptomatic  treatment  of  peripheral  paralysis 
employ  often  is  made  of  salicylic  acid,  sodium  salicylate,  and 
potassium  iodid.  In  addition,  inunctions  of  mercurial  ointment, 
potassium-iodid  ointment,  veratrin-ointment,  strychnin-ointment, 
alcoholic  applications  (camphorated  spirit,  spirit  of  formic  acid, 
spirit  of  mustard,  compound  spirit  of  angelica,  etc.),  or  subcutane- 
ous injections  of  strychnin  nitrate  (0.1 :  10 — 1^  grains  :  2\  fluidrams ; 
from  0.25  to  0.5 — 4  to  8  minims — thrice  daily)  may  be  mentioned. 

Mechanical  treatment  with  massage  of  the  paralyzed  muscles  is 
advantageous  in  order  to  stimulate  the  nutrition  of  the  muscles  as 
much  as  possible,  as  these  readily  undergo  atrophy  due  to  inac- 
tivity in  consequence  of  lack  of  use.     The  results  of  electric  treat- 


476  NERVOUS  SYSTEM 

ment  also  are  scarcely  more  than  mechanical,  inasmuch  as  after 
electric  contractions  paralyzed  muscles  emaciate  less  rapidly.  As 
long  as  paralyzed  muscles  respond  to  the  faradic  current  this 
should  be  employed,  and  with  a  well-moistened  and  firmly  applied 
electrode  movable  from  place  to  place,  while  the  other  (indifferent) 
electrode,  as  large  as  possible,  is  applied  to  the  sternum,  the  indi- 
vidual paralyzed  muscles  are  stimulated  daily  to  contract  for  from 
ten  to  twenty  times.  Care  should  be  taken  to  employ  currents 
just  strong  enough  to  cause  contraction  of  the  paralyzed  muscles, 
as  currents  of  too  great  strength  may  produce  electric  contractures 
in  the  paralyzed  muscles,  which  may  not  subside  and  may  give 
rise  to  unfortunate  disfigurement  if,  for  instance,  the  muscles  of 
the  face  are  involved.  If  the  paralyzed  muscles  do  not  respond 
to  the  faradic  current,  the  galvanic  current  should  be  employed, 
preferably  by  labile  application  :  the  anode  (+,  positive  pole)  is 
applied  to  the  sternum,  and  the  more  actively  stimulating  kathode 
( — ,  negative  pole)  is  stroked  over  each  paralyzed  muscle  from 
ten  to  twenty  times  daily.  If  a  permanent  contraction  take  place 
in  paralyzed  muscles — contracture — an  endeavor  should  be  made 
by  massage  to  prevent  increase  in  the  condition,  and  to  render 
it  more  and  more  retrogressive.  Also,  the  galvanic  current  by 
stabile  (immovable)  application  is  capable  of  overcoming  muscular 
contractures.  At  times  tenotomy  may  be  serviceable.  Certain 
kinds  of  paralysis  will  require  orthopedic  apparatus  to  neutralize 
more  or  less  completely  the  loss  of  functional  activity. 

MOTOR  PARALYSIS  OF  THE  TRIGEMINAL  NERVE 
(PARALYSIS  OF  THE  THIRD  DIVISION  OF  THE 
TRIGEMINAL  NERVE). 
The  third  or  inframaxillary  division  of  the  trigeminal  nerve 
contains  motor  nerve-fibers  for  the  muscles  of  mastication  (masse- 
ter,  temporal,  external  and  internal  pterygoid).  If  these  nerve- 
tracts  are  paralyzed,  there  will  result  motor  or  masticatory  trigem- 
inal paralysis  or  paralysis  of  the  muscles  of  mastication.  The  con- 
dition is  rare,  as  the  deep  situation  of  the  tliird  division  of  the  tri- 
geminal nerve  affords  protection  from  cold  and  external  injury. 
Pressure-paralysis  occurs  with  relative  frequency  in  consequence 
of  syphilitic  or  chronic  inflammatory  thickening  of  the  meninges, 
particularly  of  the  dura  mater  at  the  base  of  the  brain,  or  of 
aneurysms  of  the  cerebral  arteries,  or  of  syphilitic  or  tuberculous 
processes  in  the  sphenoid  bone,  if  these  cause  constriction  of  the 
oval  foramen,  through  which  the  third  division  of  the  trigeminal 
nerve  leaves  the  skull.  Intracranial  lesions  usually  involve  the 
sensory  as  well  as  the  motor  branches  of  the  trigeminal  nerve,  so 
that  in  addition  to  paralysis  of  the  muscles  of  mastication  there 
will  also  be  trioeminal  anesthesia. 


PARALYSIS  OF  THE  FACIAL  NERVE  477 

In  cases  of  unilateral  paralysis  of  the  muscles  of  mastication  it 
will  at  once  be  noted  that  if  the  patient  be  requested  to  bring  the 
teeth  firmly  together,  the  prominence  and  hardening  of  the  con- 
tracted temporal  and  masseter  muscles  can  be  seen  and  felt  only 
upon  the  healthy  side,  while  these  are  wanting  upon  the  diseased 
side.  With  each  movement  of  mastication  the  lo%ver  jaw  is  de- 
flected toward  the  paralyzed  side,  and  if  the  patient  be  requested 
to  move  the  lower  jaw  laterally  he  will  be  capable  of  doing  this 
only  toward  the  paralyzed  side,  but  not  toward  the  healthy  side, 
as  the  latter  movement  must  be  performed  by  the  paralyzed  ptery- 
goid muscles.  When  paralysis  of  the  muscles  of  mastication  has 
existed  for  some  time  the  temporal  and  masseter  muscles  may 
undergo  wasting,  and  more  or  less  deep  excavations  form  upon 
the  diseased  side  in  the  temporal  region  and  in  the  cheek. 

Bilateral  paralysis  of  the  muscles  of  mastication  is  attended 
with  drooping  of  the  lower  jaw  and  inability  to  bring  the  teeth 
together  in  mastication  or  to  move  the  jaw  laterally. 

PARALYSIS  OF  THE  FACIAL  NERVE, 

histiology.' — Peripheral  paralysis  of  the  seventh  cerebral  or 
facial  nerve  is  one  of  the  most  common  varieties  of  paralysis, 
because,  by  reason  of  its  superficial  and  comparatively  long  course, 
the  nerve  is  readily  exposed  to  refrigeratory  and  traumatic  influ- 
ences. Toxic  paralysis  of  the  facial  nerve,  as,  for  instance,  from 
lead-poisoning,  as  well  as  infectious  paralysis  (following  diphtheria, 
erysipelas,  typhoid  fever,  syphilis,  herpes  zoster),  is  rare.  Me- 
frigeratory  (j'heumatic)  paralysis  of  the  facial  nerve  occurs  with 
particular  frequency  when  one  side  of  the  face  is  exposed  to  cold 
air,  especially  while  the  body  is  over-heated.  Traumatic  paralysis 
of  the  facial  nerve  occurs  much  more  commonly.  Even  the  new- 
born may  be  attacked  by  peripheral  paralysis  of  the  facial  nerve, 
if  delivery  has  been  effected  with  forceps,  and  one  blade  of  the 
instrument,  by  reason  of  improper  application  or  of  slipping,  has 
exerted  undue  compression  of  the  trunk  of  the  nerve  at  the  ear 
or  at  its  division  on  the  cheek.  Paralysis  of  the  facial  nerve  is 
often  associated  with  disease  of  the  ear.  Tuberculous  destruction 
of  the  petrous  bone  in  particular  frequently  extends  to  the  Fallo- 
pian canal  and  the  contained  trunk  of  the  facial  nerve,  causing 
destruction  of  the  latter.  Occasionally  the  facial  nerve  is  com- 
pressed or  destroyed  and  paralyzed  by  enlargement  or  suppuration 
of  the  cervical  or  submaxillary  lymphatic  glands  or  of  the  parotid 
gland.  Incised  and  contused  wounds,  operations  upon  the  cheek, 
and  severe  blows  upon  the  ear  are  capable  of  causing  paralysis 
of  the  facial  nerve.  At  times  peripheral  paralysis  of  the  facial 
nerve  is  dependent  upon  pressure  at  the  base  of  the  skull,  and 
it  may  be  due  to  thickening  of  the  dura  mater  of  syphilitic  or 


478 


NERVOUS  SYSTEM 


chronic  infiamniatory  origin,  or  new-growths  or  aneurysms.  Also, 
fractures  of  the  skull  may  be  followed  by  peripheral  paralysis  of 
the  facial  nerve,  il'  the  nerve  be  compressed  by  hemorrhage  or 
ruptured  in  Iracture  of  the  petrous  portion  of  the  temporal  bone. 
Members  of  nervous  families  and  drunkards  appear  predisposed  to 
})aralysis  of  the  facial  nerve  in  greater  degree  than  others,  proba- 
bly because  the  resistance  of  the  nervous  tissues  to  injurious  iuHu- 
ences  of  various  kind  has  been  diminislied.     Occasionally  persons 


Fig.  60.— Facial  expression  of  a  man,  55  years  old,  presenting  severe  left-sided  trau- 
matic peripheral  paralysis  of  the  facial  nerve  ;  from  a  photograph  (personal  observation, 
Zurich  clinic). 

are  attacked  with  peripheral  paralysis  of  the  facial  nerve  a  num- 
ber of  times  in  tlie  course  of  a  few  years,  at  times  always  upon  the 
same  side,  and  at  other  times  upon  one  or  the  other  side. 

Symptoms. — Of  all  of  the  symptoms  of  peripheral  paralysis 
of  the  facial  nerve,  paralysis  of  the  muscles  of  the  face  is  found 
unexceptionally.  The  facial  nerve,  however,  sends  motor  filaments 
also  to  the  muscles  of  the  palate  and  to  the  stapedius  muscle, 
and  accordingly  paralysis  of  this  nerve  may   be  attended  with 


PARALYSIS  OF  THE  FACIAL  NERVE 


479 


distortion  of  the  uvula  and  the  arch  of  the  palate,  and  derangement 
of  hearing.  It  should  not  be  forgotten  that  the  facial  nerve  re- 
ceives from  the  trigeminal  nerve  through  the  greater  superficial 
petrosal  nerve  gustatory  fibers,  which  leave  the  trunk  of  the  facial 
nerve  through  the  chorda  tympani ;  so  that  disorders  of  taste 
are  possible  in  connection  with  facial  palsy.  Finally,  the  facial 
nerve  contains  secretory  fibers  for  the  lacrimal  and  the  salivary 
glands,  and   accordingly   derangement  in  the  secretion   of   tears 


Fig.  61.— The  same  patient  shown  in  Fig.  60,  on  laughing 


and  of  saliva  is  at  times  observed  in  connection  with  facial  palsy. 
While  paralysis  of  the  muscles  of  the  face  is  a  constant  symptom 
of  paralysis  of  the  facial  nerve,  the  occurrence  of  the  remaining 
symptoms  depends  upon  the  situation  at  which  the  trunk  of  the 
nerve  is  diseased.  Even  during  rest  the  paralyzed  side  of  the  face 
is  conspicuous  for  its  smooth,  flattened  appearance,  the  absence  of 
folds,  the  greater  size  of  the  palpebral  fissure  than  upon  the 
healthy  side,  the  eversion  of  the  lower  eyelid,  the  fulness  of  the 
conjunctival  sac  with  tears,  and  often  the  flow  of  tears  over  the 


48U 


NER  VO  US  SYSTEM 


lower  lid  across  the  cheek — so-called  epiphora.  The  attention  of 
the  observer  is  particularly  attracted  by  the  unusual  phenomenon 
that  closure  of  the  eyelids  takes  place  only  upon  the  healthy  side, 
while  the  eye  upon  the  diseased  side  remains  constantly  open 
(Fig.  60).  The  paralyzed  side  of  the  face  appears  drawn  toward 
the  healthy  side.  The  difference  between  the  paralyzed  and  the 
healthy  side  of  the  face  becomes  the  more  marked  during  laughter 
or  on  cryingj  for  the  paralyzed  side  remains  immobile,  inanimate, 


Fig  62.— The  same  patient  shown  in  Figs.  60  and  61,  when  an  attempt  is  made  to  close  the 

eyes. 


and  mask-like,  while  the  healthy  side  undergoes  natural  furrow- 
ing and  alterations  (Fig.  61). 

In  order  to  study  more  carefully  the  paralysis  of  individual 
muscles,  it  is  well  to  request  the  patient  to  perform  given  move- 
ments with  the  muscles  of  the  face.  It  will  at  once  be  observed 
that  the  forehead,  even  during  rest,  is  free  from  furrows,  as  com- 
pared with  the  healthy  side.  If  the  patient  be  requested  to 
wrinkle  the  forehead,  horizontal  furrows  appear  only  upon   the 


PARALYSIS  OF  THE  FACIAL  NERVE  481 

healthy  side,  ending  at  the  middle  line,  while,  in  consequence  of 
paralysis  of  the  frontal  muscle,  no  furrows  are  formed  upon  the 
diseased  side.  Paralysis  of  the  corrugator  muscle  of  the  eyebrow  is 
indicated  by  the  fact  that  the  brow  upon  the  paralyzed  side  is 
lower  than  that  upon  the  healthy  side,  and  that  on  wrinkling  the 
forehead  vertical  furrows  become  apparent  only  over  the  glabella 
upon  the  healthy  side.  The  greater  width  of  the  palpebral  fissure 
upon  the  diseased  side  is  due  to  paralysis  of  the  orbicular  muscle 
of  the  eyelids.  The  action  of  the  elevator  muscle  of  the  eyelid, 
innervated  by  the  oculomotor,  then  preponderates,  drawing  the 
upper  lid  upward,  so  that  in  comparison  with  the  healthy  side 
the  fissure  appears  reduced  in  size.  To  the  same  circumstance  is 
due  the  eversiou  of  the  lower  eyelid — paralytic  ectropion.  Paraly- 
sis of  the  muscle  of  Horner,  a  portion  of  the  orbicular  muscle 
toward  the  nasal  aspect,  is  attended  with  displacement  of  the 
lacrimal  caruncle,  so  that  the  tears  do  not  properly  enter  it  and 
the  duct  continuous  with  it.  This  circumstance  explains  the  fact 
that  the  eye  upon  the  paralyzed  side  is  constantly  bathed  in  an 
excess  of  tears,  and  that  frequently  tears  flow  over  the  lower  eye- 
lid and  upon  the  cheek — so-called  epiphora.  In  consequence,  the 
nasal  mucous  membrane  remains  dry,  and  the  patients  complain 
of  dryness  and  burning  in  the  nose  upon  the  paralyzed  side,  and 
also  of  impairment  of  the  sense  of  smell. 

Marked  disfigurement  of  the  face  results  in  consequence  of 
absence  of  winking  upon  the  paralyzed  side,  and  even  if  the  finger 
be  applied  to  the  eyeball  or  the  cornea  is  touched  reflex  closure  of 
the  eye  fails  to  take  place.  The  disfigurement  becomes  particularly 
marked  if  the  patient,  when  requested,  attempts  to  close  the  eves, 
only  the  eye  upon  the  healthy  side  being  closed,  while  that  upon 
the  diseased  side  remains  open — paralytic  lagophthalmos — and  be- 
tween the  lids  the  white  sclera  and  generally  also  a  small  portion 
of  the  cornea  become  visible  as  the  eyeball  is  rolled  ujjward  and 
inward  on  closure  of  the  eyes  (Fig.  62). 

Frequently,  on  attempting  to  close  the  eyes,  a  narrowing  of  the  palpebral 
fissure  upon  the  paralyzed  side  is  observed  that  has  been  attributed  to  syner- 
gistic relaxation  of  the  elevator  of  the  lids. 

The  tip  of  the  nose  is  deflected  toward  the  healthy  side,  while 
upon  the  diseased  side  the  entrance  to  the  nares  appears  reduced 
in  size.  On  deep  inspiration  the  ala  of  the  nose  upon  the  diseased 
side  is  drawn  toward  the  septum.  Persons  capable  of  moving 
the  nasal  aire  voluntarily  are  able  in  the  presence  of  facial  paraly- 
sis to  make  such  movement  only  upon  the  healthy  side.  Also,  the 
buccal  orifice  and  the  chin  are  drawn  toward  the  healthy  side. 
The  angle  of  the  mouth  is  lower  upon  the  paralyzed  than  upon 
the  healthy  side,  in  consequence  of  paralysis  of  the  elevator  muscle 
of  the  angle  of  the  mouth.     Whistling  and  distention  of  the  cheeks 

31 


482  NERVOUS  SYSTEM 

with  air  are  impossible,  because  the  lips  cannot  be  closed  upon  the 
paralyzed  side,  and  the  air  is  thus  permitted  to  escape  from  the 
mouth.  Also  in  speakin^^,  and  particularly  in  the  use  of  the  labials 
(b,  p,  f,  V,  w),  disturbances  and  secondary  sounds  are  appreciable, 
and  also  in  the  articulation  of  certain  vocal  sounds  (a,  e).  In  eat- 
ing and  drinking,  the.ingesta  readily  escape  between  the  paralyzed 
and  separated  li])s,  so  that  some  patients  are  compelled  to  perform 
these  acts  with  the  head  thrown  backward. 

In  consequence  of  paralysis  of  the  buccinator  muscle  the  act 
of  mastication  is  interfered  with.  The  cheeks  are  not  rendered 
sufficiently  tense,  and  as  a  result  the  mucous  membrane  of  the 
cheek  is  readily  caught  between  the  teeth  in  the  act  of  chewing, 
and  is  bitten.  Also,  food  readily  finds  its  way  between  the 
mucous  membrane  of  the  cheek  and  the  teeth,  and  must  be  re- 
moved with  the  fingers  or  by  pressure  upon  the  cheek  from  with- 
out. At  times  the  base  of  the  tongue  appears  lower  upon  the  dis- 
eased than  upon  the  healthy  side  in  consequence  of  paralysis  of 
the  stylohyoid  and  digastric  muscles.  If  the  muscles  of  the  soft 
palate  are  involved  in  paralysis  of  the  facial  nerve,  the  tip  of  the 
uvula  is  deflected  toward  the  healthy  side,  and  the  arch  of  the 
palate  not  only  assumes  a  lower  level,  as  compared  with  the 
healthy  side,  but  on  active  respiration  flaps  like  a  loose  sail. 

Paralysis  of  the  musculature  of  the  cheek  is  revealed  not  only, 
as  has  been  mentioned,  by  disturbances  in  mastication,  but  also  by 
obliteration  or  depression  of  the  nasolabial  fold.  In  animated 
conversation,  Avith  respiratory  movement,  and  during  sleep  the 
paralyzed  cheek  flaps  to  and  fro  like  a  curtain. 

Paralysis  of  the  muscles  of  the  auricle  and  of  the  occipital 
muscle  is  frequently  demonstrable  only  with  difficulty,  because 
not  many  persons  are  capable  of  moving  the  auricle  voluntarily. 
Naturally,  the  movements  of  the  auricle  would  be  wanting  u])on 
the  paralyzed  side.  Examination  of  the  muscles  by  means  of  the 
faradic  and  the  galvanic  current  could  yet  be  practised,  althougli 
alterations  in  electric  muscular  irritability  would  be  ex])ected  only 
in  the  presence  of  moderately  severe  paralysis.  Involvement  of 
the  stapedius  muscle  in  paralysis  of  tlie  fiicial  nerve  will  be  indi- 
cated by  excessive  acuity  of  hearing — oxyokoia  (Willisian  hyper- 
acusis) — which  is  ox]i]ained  by  the  preponderant  action  of  tiie 
tensor  tympani  muscle. 

Paralysis  of  the  jdatysma  myoidcs  can  be  recognized  from  the 
fact  that  on  marked  depression  of  the  lower  lip  contraction  of  the 
platysma  on  the  paralyzed  side,  Avith  the  formation  of  folds  in  the 
skin  of  the  neck,  does  not  occur. 

It  is  noteworthy  that  peripheral  facial  palsy  is  attended  with 
absence  of  all  reflex  and  associated  movements.  ^Movement  of  tlie 
fingers  toward  the  eye  or  contact  witli  the  cornea  fails  to  induce 
closure  of  the  lids,  and  in  crying,  laughing,  and  yawning  the 


PABALYSIS   OF  THE  FACIAL   XERVE  483 

paralyzed  side  remains  immobile  and  inanimate.  Disturbances  of 
taste  are  only  to  be  expected  in  association  with  peripheral  facial 
palsy  when  the  lesion  is  situated  between  the  geniculate  ganglion 
and  the  origin  of  the  chorda  tympaui.  They  involve  always  only 
the  anterior  two-thirds  of  the  tongue,  as  the  posterior  third  is  sup- 
plied with  gustatory  fibers  by  the  glossopharyngeal  nerve.  Often 
the  patient  complains  of  diminislied  tactile  sensibility  of  the  tongue 
on  the  paralyzed  side. 

Examination  of  tlie  sense  of  taste  is  made  most  simply  by  dipping  rolls 
of  bibulous  paper  successively  in  solutions  of  common  salt,  vinegar,  sugar, 
and  quinin,  and  toucbing  the  anterior  two-tbirds  of  tbe  tongue  upon  one 
and  tben  upon  tbe  otber  side.  Tbe  patient  should  retract  the  tongue  into 
the  mouth  only  after  he  has  appreciated  a  distinct  gustatory  sensation. 
Bitter  solutions  are  tested  last,  because  they  leave  an  after-taste  for  a  long 
time.  It  is  advisable  to  test  the  sense  of  taste  also  by  means  of  the 
galvanic  current  and  a  gustatory  electrode. 

Some  patients  complain  of  dryness  of  the  mouth  upon  the  para- 
lyzed side,  and  this  condition  is  associated  with  disorders  in  the 
secretory  branches  of  the  facial  nerve  to  the  salivary  glands. 
If  the  nerve-fibers  for  the  lacrimal  gland  upon  the  paralyzed  side 
are  also  involved,  secretion  of  tears  takes  place  on  crying  only 
upon  the  healthy  side.  Sensory  disturbances  are  wanting  in  cases 
of  pure  facial  palsy.  Nevertheless,  cutaneous  anesthesia  is  now 
and  then  observed  upon  the  paralyzed  side,  and  particularly  if, 
as  a  result  of  the  action  of  peripheral,  injurious  influences,  in  addi- 
tion to  the  fibers  of  the  facial  nerve,  also  the  terminal  fibers  of  the 
intimately  related  trigeminal  nerve  are  involved. 

The  occurrence  of  facial  palsy  is  at  times  preceded  by  pro- 
dromes, such  as  vertigo,  headache,  mental  confusion,  ringing  in 
the  ears,  impairment  of  hearing,  and  pain  in  the  ear.  At  other 
times  the  paralysis  follows  immediately  upon  the  action  of  the 
injurious  influence  (cold,  injury).  Often  the  attention  of  the  pa- 
tient is  directed  by  his  friends  to  the  distortion  of  the  face  and 
the  paralysis  of  the  facial  nerve.  In  other  instances  he  is  induced 
by  a  sense  of  tension,  impaired  motility,  difficulty  in  eating,  speak- 
ing, and  whistling,  to  resort  to  the  use  of  a  mirror,  when  the 
alteration  upon  one  side  of  the  face  is  noticed.  At  times  the 
disorder  is  discovered  quite  accidentally  on  using  the  mirror  in 
the  performance  of  the  toilet.  Whether  the  paralysis  is  of  mild 
degree,  of  moderate  severity,  or  profound  can  be  determined  alone 
by  electric  examination  (p.  473).  Should  there  be  no  electric  appa- 
ratus at  hand,  the  mechanical  irritability  of  the  paralyzed  muscles 
should  be  tested,  for  increased  mechanical  muscular  irritability 
and  tardy  muscular  contractions  are  indicative  of  a  moderately 
severe  or  a  profound  paralysis.  After  the  paralysis  of  the  facial 
muscles  has  existed  for  some  time  muscular  icasting  gradually 
ensues — atrophy  due  to  inactivity. 

Profound  paralysis  of  the  facial  nerve  may  persist  through- 


484 


NERVOUS  SYSTEM 


out  the  remainder  of  life,  but  often  only  partial  improvement 
ensues,  some  muscles  of  the  face  regaining  their  motility,  while 
others,  on  the  other  hand,  remain  paralyzed  permanently.  Per- 
sistent muscular  contraction  may  readily  develop  in  paralyzed 
muscles — muscular  contracture — and  the  previously  smooth  and 
unfurrowed  paralyzed  side  of  the  face  now  becomes  distorted 
by  unusually  deep  furrows.  Involuntary  contractioTis  also  occur 
frequently  in  the  paralyzed  muscles,  and  these  may  also  be  in- 
duced voluntarily  by  slight  cutaneous  irritation.  Often  an  abnor- 
mally increased  tendency  to  associated  movements  is  noticeable. 


Fig.  63.— Facial  expression  in  a  case  of  bilateral  facial  paralysis:  from  a  photograph 
(personal  observation,  Zurich  clinic). 

On  closure  of  the  eyes,  for  instance,  twitching  occurs  at  the  angle 
of  the  mouth,  or,  on  puckering  the  lips,  contraction  of  the  palpebral 
fissure.  Long-continued  paralysis  of  the  facial  nerve  may  be  fol- 
lowed by  disease  of  the  eye,  for  in  the  absence  of  winking,  and  if 
the  cornea  is  not  moistened  with  tears  and  cleared  of  foreign  bodies 
from  the  air,  there  will  be  danger  of  inflammation  of  the  cornea 
(keratites),  rupture  of  the  cornea,  and  loss  of  the  eyeball  (pan- 
ophthalmitis). 

Among  rare  complications  of  peripheral  facial  palsy,  vasomotor  and  trophic 
disturbances  appear  at  times  upon  the  paralyzed  side,  such  as  pallor  of  the 


PARALYSIS  OF  THE  FACIAL  NERVE 


485 


skin,  grayness  of  the  hair,  labial,  lingual,  and  pharyngeal  herpes.  The 
herpes  may  precede  the  paralysis  or  follow  it  after  the  lapse  of  a  few  days. 
At  times  hyperidrosls  appears  upon  the  paralyzed  side. 

Peripheral  paralysis  of  the  facial  nerve  is  generally  unilateral 
— -facial  hemiplegia  ;  bilateral  paralysis  of  the  facial  nerve — -facial 
diplegia — is  encountered  but  rarely.  Either  the  latter  is  the 
result  of  tuberculous  disease  of  both  petrous  bones,  paralysis  in- 
volving at  first  the  one  and  then  the  other  facial  nerve ;  or  it  is 
associated  with  lesions  at  the  base  of  the  skull,  and  here  at  times 
simultaneously  if  the  basal  disease  involves  both  facial  nerves  at 


/i-'riiil^ 


Fig.  G4. — The  same  patient  as  in  Fig.  63,  on  attempting  to  close  the  eyes. 


the  same  time ;  or  both  nerves  may  be  affected  in  quick  succession 
by  cold  or  external  injuries.  Further,  examples  are  known  also 
in  which  the  facial  nerve  upon  one  side  was  paralyzed  as  a  result 
of  peripheral  influences,  and  that  upon  the  opposite  side  as  a  result 
of  central  influences,  the  arm  and  the  leg  being  involved  addi- 
tionally in  the  paralysis  in  association  with  the  latter,  with  the 
development  of  the  clinical  picture  of  cerebral  hemiplegia.  In 
the  presence  of  facial  diplegia  the  face  has  lost  its  power  of  ex- 
pression upon  both  sides,  remains  inanimate,  and  resembles  a 
mask.     The  patients  may  be  heard  to  laugh  or  shout  or  cry,  but 


486  NERVOUS  SYSTEM 

the  facial  expression  remains  rigid  and  unaltered.  The  upper 
lip  not  rarely  droops  like  a  proboscis,  while  the  lower  lip  is 
everted.  The  imperfect  closure  of  the  lips  prevents  in  marked 
degree  the  ingestion  of  nutriment,  because  food  and  drink  readily 
escape  from  the  mouth.  Often  the  patients  introduce  the  food 
deeply  into  the  pharynx  with  the  fingers,  a  spoon,  or  a  specially 
devised  wooden  spatula,  in  order  to  facilitate  swallowing.  AMien 
the  patient  is  requested  to  close  the  eyes  both  palpebral  fissures 
persist  (Figs.  63  and  64). 

Anatomic  Alterations. — Little  is  known  with  regard  to 
the  anatomic  alterations  of  peripheral  fiicial  paralysis,  because  the 
disorder  is  not  fatal,  and  because  if  death  should  result  accident- 
ally from  other  causes  the  removal  of  the  nerve  and  the  facial 
muscles  will  not  be  permitted  on  account  of  the  unavoidable 
mutilation  of  the  fice.  In  severe  cases  of  rheumatic  or  traumatic 
paralysis  of  the  facial  nerve  destruction,  fatty  degeneration,  and 
disappearance  of  the  medullary  sheaths  and  axis-cylinders,  and 
multiplication  of  the  nuclei  of  the  sheaths  of  Schwann,  have  been 
found  in  the  peripheral  portions  of  divided  nerves.  The  connec- 
tive tissue  of  the  nerves  has  generally  been  unaltered.  Fatty 
degeneration  had  taken  place  in  the  paralyzed  facial  muscles. 

Mild  facial  paralysis  is  perhaps  attended  with  scarcely  more  than  active 
over-distention  of  the  vessels  with  blood,  and  slight  exudation  into  the 
connective-tissue  nerve-sheath,  Avith  compression  of  the  nerve-fibers,  with- 
out extensive  nerve-degeneration.  Therefore,  these  conditions  are  suscep- 
tible of  speedy  involution. 

Diagnosis. — The  recognition  of  peripheral  facial  palsy  is 
easy  on  account  of  the  striking  distortion  of  the  face.  In  con- 
tradistinction from  central  facial  paralysis,  all  of  the  facial  muscles 
are  involved,  while  with  central  facial  paralysis  the  branch  to  the 
forehead  remains  uninvolved,  so  that  the  patient  is  capable  of 
wrinkling  the  forehead  and  eyebrows,  and  of  closing  the  eyes. 
In  addition,  with  central  paralysis  reflex  and  associated  move- 
ments are  preserved  ;  phenomena  of  degenerative  electric  reaction 
are  wanting ;  and,  finally,  the  arm  and  the  leg  are,  as  a  rule, 
involved,  so  that  a  condition  of  hemiplegia  exists.  Only  with 
disease  of  the  bones  does  facial  jwralysis  preserve  its  peripheral 
character  if  the  lesion  involves  the  intrapontine  facial  path  from 
the  point  of  exit  of  the  facial  trunk  at  the  posterior  peduncle  of 
the  pons  to  the  facial  nucleus,  or  the  latter  itself.  Other  pontine 
symptoms  (interference  with  swallowing,  contracted  pupils,  dif- 
ficulty in  articulation)  will  then  usually  be  present  also,  and  fre- 
quently also  paralysis  of  the  extremities. 

The  seat  of  peripheral  facial  paralysis  can  be  readily  deter- 
mined with  the  aid  of  the  accompanying  diagram  representing  the 
course  of  the  facial  nerve  (Fig.  65). 

1.  If  the  lesion  is  situated  outside  the  stylomastoid  foramen,  the 


PARALYSIS  OF  THE  FACIAL  NERVE 


487 


paralysis  will  be  confined  to  the  muscles  of  the  face  alone  (Fig. 
65,1). 

2.  A  lesion  in  the  loivermost  portion  of  the  Fallopian  canal  will 
be  attended  in  addition  with  paralysis  of  the  posterior  auricular 
nerve,  and  consequently  of  the  muscles  of  the  auricle  and  the  occip- 
ital muscle  (Fig.  65,  2). 

3.  When  the  lesion  is  situated  above  the  point  of  origin  of  the 
chorda  tympani  nerve  there  will  be,  in  addition  to  paralysis  of  the 


-nap. 


Fig.  65.— Diagram  of  the  distribution  of  the  facial  nerve  :/c,  trunk  of  the  facial  nerve; 
ac,  trunk  of  the  auditory  nerve ;  pai,  internal  auditory  canal ;  Gg,  geniculate  ganglion'; 
psm,  greater  superficial  petrosal  nerve  ;  sip,  stapedius  nerve ;  cht,  chorda  tympani ;  Jst, 
styloid  foramen ;  nap,  posterior  auricular  nerve  ;  bv  and  sth,  nerves  for  the  digastric  and. 
stylohyoid  muscles ;  gsz,  facial  branches ;  trg,  trg',  trg",  trg"',  trunk  and  three  branches  of 
the  trigeminal  nerve ;  Gsp,  sphenopalatine  ganglion  ;  Ig,  lingual  nerve. 


muscles  of  the  face  and  of  the  auricle,  also  disturbances  in  the 
sense  of  taste  and  of  the  secretion  of  saliva  (Fig.  65,  3). 

4.  If  the  facial  nerve  is  diseased  between  the  point  of  origin  of 
the  stapedius  nerve  and  the  geniculate  ganglion,  disorders  of  hear- 
ing (oxyokoia)  will  be  observed,  in  addition  to  paralysis  of  the 
muscles  of  the  face,  the  auricle,  and  the  occipital  muscle,  and  to 
disturbances  in  the  sense  of  taste  and  in  the  secretion  of  saliva 
(Fig.  65,4). 

5.  Disease  of  the  geniculate  ganglion  itself  will  be  attended,  in 
addition  to  paralysis  of  the  facial  muscles,  the  muscles  of  the  au- 
ricle, the  occipital  muscle,  disturbances  in  the  sense  of  taste,  in 


488  NERVOUS  SYSTEM 

the  secretion  of  saliva,  and  in  the  sense  of  Iiearing,  also  with 
j)(ir((/i/fiis  of  the  ui-ii/a  and  auppreasion  of  tlie  .secretion  of  tears,  as 
the  fibers  of  tlie  facial  nerve  governing  the  functions  last  named 
leave  the  path  of  the  nerve  at  the  geniculate  ganglion,  in  order 
to  join  the  path  of  the  trigeminus  through  the  greater  superficial 
petrosal  nerve  (Fig.  65,  o). 

6,  Lesions  aboce  the  geniculate  fjangJion  will  be  attended  with 
all  of  the  manifestations  of  facial  palsy  except  disturbances  in  the 
sense  of  taste.  There  will  thus  be  present  paralysis  of  the  uvula, 
derangement  in  the  secretion  of  tears,  in  the  sense  of  hearing,  in 
the  secretion  of  saliva,  paralysis  of  the  facial  muscles  and  those 
of  the  auricle,  and  the  occipital  muscle. 

The  prognosis  and  the  treatment  will  be  governed  by  the 
rules  laid  down  on  pp.  475  and  47(3. 

PARALYSIS  OF  THE  SPINAL  ACCESSORY  NERVE. 

In  the  discussion  of  peripheral  paralysis  of  the  spinal  accessory 
nerve  the  motor  accessory  fibers  that  enter  the  vagus,  and  supply 
especially  the  muscles  of  the  larynx  and  the  pharynx,  and  pass  to 
the  cardiac  plexus,  are  omitted  from  consideration.  The  condi- 
tion to  be  described  is  attended  only  with  jmrali/sis  of  the  sterno- 
mastoid  and  the  trapezius.  Most  commonly,  paralysis  of  the  spinal 
accessory  nerve  is  of  traumatic  origin,  as  this  nerve  pursues  a  long 
and  superficial  course  upon  either  side  of  the  neck.  Stab-wounds, 
operation-wounds,  suppurating  cervical  lymphatic  glands,  destroy- 
ing the  trunk  of  the  spinal  accessory  nerve,  are  relatively  frequent 
causes  of  such  paralysis.  Nevertheless,  paralysis  of  the  spinal 
accessory  nerve  is  one  of  the  less  common  varieties  of  periplieral 
paralysis.  At  times  paralysis  of  the  spinal  accessory  is  dependent 
upon  disease  of  the  cervical  vertel)rse,  as  it  sends  numerous  root- 
iilaments  to  the  level  of  the  seventh  cervical  vertebra. 

In  the  presence  of  unilateral  paralysis  of  the  sternocleidomastoid 
muscle  the  head  and  the  chin  acquire  an  abnormal  position,  in  con- 
sequence of  predominant  activity  of  the  healthy  sternomastoid. 
The  head  and  the  chin  are  directed  toward  the  parali/zed  side, 
and  the  chin  is  elevated.  Rotation  of  the  head  in  the  opposite 
direction  is  greatly  interfered  with.  AVhen  the  patient  lies  upon 
his  back  and  attempts  to  raise  his  head  the  contracted  sternomas- 
toid  becomes  apparent  beneath  the  skin  only  upon  the  healthy  side 
of  the  neck.  Also,  on  deep  inspiration  only  the  healthy  and  not 
the  paralyzed  sternomastoid  undergoes  contraction.  If  the  paral- 
ysis has  existed  for  some  time,  a  depression  in  the  course  of  the 
neck  is  observed  upon  the  paralyzed  side,  resulting  from  inactivity- 
atrophy  of  the  paralyzed  sternomastoid.  At  times  the  healthy 
sternomastoid  undergoes  contracture,  with  the  development  of 
spasmodic  torticollis,  which  greatly  prevents  rotatory  movement  of 


PARALYSIS  OF  THE  HYPOGLOSSAL  NERVE  489 

the  head.  In  the  presence  of  bilateral  paralysis  of  the  sternomas- 
toid  the  patient  is  almost  wholly  incapable  of  raising  his  head 
from  the  recumbent  posture. 

Paralysis  of  the  trapezius  muscle  is  indicated,  on  inspection  of 
the  patient  from  the  front,  by  the  fact  that  the  supraclavicular 
fossa,  upon  the  paralyzed  side  is  unusually  deep,  and  the  shoulder 
is  lower.  Viewed  from  the  posterior  aspect  the  scapula  upon  the 
paralyzed  side  is  lower  than  upon  the  healthy  side.  At  the  same 
time,  the  scapula  upon  the  paralyzed  side  stands  off  a  greater  dis- 
tance from  the  vertebral  column,  its  upper  and  outer  angle  being 
drawn  markedly  forward  and  downward  by  the  weight  of  the  arm, 
while  the  inferior  angle  is  more  closely  approximated  to  the  verte- 
bral column.  3Iovement  of  the  scapula  is  rendered  difficult,  as  it 
can  be  accomplished  only  by  contraction  of  the  elevator  of  the 
angle  of  the  scapula.  The  act  of  approximating  the  scapula  to  the 
vertebral  column  is  rendered  difficult,  and  is  possible  only  through 
the  agency  of  the  rhomboid.  Elevation  of  the  arm  above  the  hori- 
zontal level  is  attended  with  difficulty,  because  the  scapula  is  imper- 
fectly fixed.  Further,  the  external  free  border  of  the  paralyzed 
trapezius  does  not  form  a  straight  line,  but  a  curved  line,  with  its 
convexity  directed  toward  the  vertebral  column.  In  the  presence 
of  bilateral  paralysis  of  the  trapezius  the  back  appears  unusually 
wide.  In  addition,  the  conditions  just  described  are  present  on 
both  sides. 

PARALYSIS  OF  THE  HYPOGLOSSAL  NERVE. 

Peripheral  paralysis  of  the  hypoglossal  nerve  gives  rise  to 
paralysis  of  the  tongue — glossoplegia.  The  paralysis  of  the  tongue 
in  turn  is  characterized  in  part  by  disorders  of  mastication  and  in 
part  by  disorders  of  speech,  and  accordingly  it  may  be  divided 
into  masticatory  and  articulatory  glossoplegia.  Hypoglossal  palsy 
is  most  commonly  of  traumatic  origin,  resulting  especially  from 
punctured  and  incised  wounds,  or  from  pressure  exerted  by  en- 
larged lymphatic  glands  or  other  tumors  of  the  neck.  I  have 
recently  treated  a  woman  with  hypoglossal  paralysis  in  the 
sequence  of  syphilis,  induced  by  gummatous  hyperplasia  upon  the 
dura  at  the  base  of  the  skull.  After  a  course  of  treatment  with 
inunctions  of  mercurial  ointment  and  the  internal  administration 
of  potassium  iodid  complete  recovery  ensued. 

Unilateral  hypoglossal  paralysis  is  attended  with  deviation  of 
the  tip  of  the  tongue  toumrd  the  paralyzed,  side  in  consequence  of 
preponderant  action  of  the  healthy  genioglossus  muscle.  The 
dorsum  of  the  tongue  is  the  more  greatly  arched  upon  the  para- 
lyzed side.  The  diseased  half  of  the  tongue  exhibits  more  marked 
furroioing  of  its  surface,  and  often  also  active  fibrillary  twitching. 
In  chewing,  the  food  readily  remains  upon  the  paralyzed  half  of 


490  NERVOUS  SYSTEM 

the  tongue,  and  the  patients  often  complain  in  consequence  of 
imperfect  distribution  of  the  food  in  tlie  mouth  and  of  defective 
taste.  In  the  act  of  deglutition  deficient  propulsion  of  the  food  is 
appreciable,  and  the  approximation  of  the  tongue  to  the  palate  is 
incomplete,  so  that  food  may  readily  return  into  the  mouth.  The 
swallowing  of  saliva  may  also  be  interfered  with,  and  the  patient 
in  consequence  often  permits  dribbling  from  the  mouth.  In  speak- 
ing, the  imperfect  articulation,  particularly  of  the  lingual  letters 
(d,  t,  s,  sch,  1,  r,  k,  g,  ch),  will  be  noted.  If  the  paralysis  has 
existed  for  some  time,  unilateral  atrophy  of  the  tongue  takes  place. 
In  cases  of  bilateral  hypoglossal  paralysis  the  tongue  is  con- 
verted into  an  immobile  muscular  mass.  The  formation  of  a  bolus 
is  scarcely  possible,  and  speech  is  reduced  to  an  inarticulate  grunt 
or  jargon,  so  that  the  patient  can  often  make  himself  understood 
only  in  writing. 

MULTIPLE  OR  COMBINED  PARALYSIS  OF 
CEREBRAL  NERVES. 

In  the  presence  of  multiple  or  combined  paralysis  of  cerebral 
nerves  several  cerebral  nerves  may  be  paralyzed  together.  At 
times  almost  all  of  the  cerebral  nerves  upon  one  side  are  paralyzed, 
while  in  other  instances  some  nerves  may  be  paralyzed  upon  one 
side  and  others  upon  the  opposite  side  of  the  body.  Such  a  con- 
dition is  most  commonly  associated  with  lesions  at  the  base  of  the 
skull,  which  extend  gradually  and  involve  one  nerve  after  the 
other.  Particularly,  syphilitic,  carcinomatous,  and  tuberculous 
lesions  of  the  meninges  and  the  cranial  bones  are  the  etiologic  factors. 
Less  commonly,  aneurysms  of  the  cerebral  arteries  or  fracture  of 
the  base  of  the  skull  is  the  cause  of  the  disorder.  At  times  multiple 
paralysis  of  cerebral  nerves  occurs  in  the  sequence  of  infectious 
diseases,  as,  for  instance,  after  pharyngeal  diphtheria.  It  occurs 
occasionally,  also,  in  the  course  of  polyneuritis.  Injuries  in  the 
iqjper  poiiion  of  the  cervical  region  are  likewise  capable  of  causing 
paralysis  simultaneously  of  several  cerebral  nerves.  In  the  dif- 
ferential diagnosis  paralysis  due  to  lesions  of  the  nuclei  of  the 
cerel)ral  nerves  in  the  medulla  oblongata  and  in  the  pons  is  par- 
ticularly to  be  taken  into  consideration.  The  etiology  and  the 
mode  of  development  of  the  palsy  afford  the  principal  means  of 
distinction  in  the  differential  diagnosis. 

PARALYSIS  OF  THE  PHRENIC  NERVE. 

The  phrenic  nerve,  wdiich  receives  fibers  from  the  third  and 
fourth  cervical  nerves,  is  paralyzed  at  times  in  consequence  of 
injuries,  as,  for  instance,  fractures,  luxations,  neoplasms  of  the 
cervical  vertebrae,  tumors,  abscesses,  punctured  and  incised  wounds 


PARALYSIS  OF  THE  PHRENIC  NERVE  491 

of  the  neck.  Infectious  paralysis  of  the  phrenic  nerve  has  been 
observed  also  in  the  sequence  of  diphtheria  and  influenza.  Toxic 
paralysis  has  been  noted  in  the  sequence  of  poisoning  with  lead, 
alcohol,  carbon  monoxid,  and  opium.  At  times  refrigeratory 
paralysis  is  observed.  It  is  noteworthy  that  paralysis  of  the 
diaphragm  is  much  more  commonly  of  myopathic  than  of  neuro- 
pathic origin ;  that  is,  dependent  not  upon  disease  of  the  phrenic 
nerve,  but  upon  disease  of  the  diaphragm  itself.  Such  a  condi- 
tion occurs  particularly  in  association  with  diaphragmatic  pleurisy 
and  peritonitis,  because  the  inflammation  of  the  serous  membrane 
readily  extends  to  the  muscular  structure  of  the  diaphragm,  whose 
function  is  thereby  deranged.  Paralysis  of  the  diaphragm  may 
involve  a  number  of  circumscribed  areas,  or  be  unilateral  or 
bilateral. 

Bilateral  or  comjjlete  paralysis  of  the  diaphragm  is  a  most 
dangerous  disorder,  as  death  may  result  from  asjjhyxia.  During 
quiet  breathing  symptoms  may  naturally  be  absent,  but  these 
appear  at  once  upon  active  bodily  exercise,  as,  for  instance,  in 
ascending  stairs.  It  is  noteworthy  that  the  type  of  respiration  is 
purely  costal,  and  that  principally  the  upper  portion  of  the  thorax 
moves  in  the  act  of  breathing,  while  the  lower  remains  immobile 
and  appears  unusually  full.  In  contrast  with  normal  conditions 
inspiratory  retraction  and  expiratory  protrusion  of  the  epigastrium 
take  place.  The  upper  border  of  the  liver  is  unusually  high,  and 
scarcely  participates  in  the  respiratory  movements.  The  latter, 
however,  are  reversed  as  compared  with  the  normal.  The  liver 
ascends  with  inspiration,  as  does  also  its  lower  border,  whose 
movement  frequently  can  be  followed  with  the  finger.  All  ex- 
pulsive efforts  (coughing,  defecation,  heavy  lifting,  vomiting,  loud 
and  continued  speaking  or  singing)  are  difficult  and  incomplete. 
Even  slight  catarrhal  states  of  the  air-passages  may  at  times  be 
attended  with  danger  of  asphyxia,  because  in  consequence  of 
deficient  cough  and  expectoration  accumulation  of  secretion  in  the 
air-passages  readily  takes  place.  The  greater  the  embarrassment 
of  respiration  the  more  rapid  becomes  the  act  of  breathing  and 
the  greater  the  cyanosis. 

To  overcome  the  dangers  of  paralysis  of  the  diaphragm  electric 
treatment  particularly  is  to  be  advised.  The  phrenic  nerve  will 
be  found  in  the  angle  formed  between  the  sternomastoid  and  the 
omohyoid  muscles.  In  this  situation  upon  either  side  an  electrode 
is  placed,  and  a  strong  faradic  current  is  passed  through  the  dis- 
eased nerve,  with  interruption  by  means  of  a  suitable  device  corre- 
sponding to  the  rhythm  of  normal  breathing.  Contraction  of  the 
diaphragm  will  be  recognized  from  the  fact  that  air  enters  the  air- 
passages  with  a  gurgling  sound  and  the  epigastrium  bulges  with 
inspiration. 


492  NERVOUS  SYSTEM 

PARALYSIS  OF  THE  RADIAL  NERVE. 

Htiology. — As  the  facial  is  the  most  commonly  paralyzed  of 
the  cerel)ral  nerves,  so  among  the  nerves  of  the  arm  the  radial  is 
by  far  the  most  commonly  affected  by  peripheral  paralysis.  Its 
long  and  superficial  course  affords  a  favorable  point  of  attack  for 
external  injurious  influences.  Only  rarely  is  radial  paralysis  due 
to  refrigeratory  or  infectious  causes.  Radial  paralysis  of  toxic 
orir/in  is  distinctly  more  common.  For  a  long  time  it  has  been 
known  particularly  that  under  the  influence  of  lead  (saturnism) 
radial  paralysis  occurs  not  rarely.  This  saturnine  paralysis  of  the 
radial  nerve  is  characterized  by  its  bilateral  distribution.  Toxic 
radial  paralysis  may,  however,  occur  also  as  a  result  of  the  action 
of  alcohol.  It  has  often  been  observed  after  injections  of  ether, 
antvpyrin,  and  osmic  acid  beneath  the  skin  of  the  forearm. 
Traumatic  radial  paralysis  is  the  most  common  variety.  Sleep- 
paralysis  is  the  best  known  form,  occurring  during  sleep  when 
the  patient  places  the  forearm  (usually  tlie  right)  in  such  a  posi- 
tion that  the  radial  nerve  is  compressed,  and  as  a  result  is  para- 
lyzed. At  times  the  patient  has  supported  himself  upon  his  arm, 
resting  the  upper  arm  upon  a  sharp  edge,  or  permitting  the  arm 
to  hang  over  a  sharp  edge  (arm  of  a  chair  or  edge  of  tlie  bed),  or 
the  patient  has  slept  with  the  arm  beneath  the  head,  the  upper 
arm  being  thereby  unduly  compressed  upon  its  dorsal  aspect,  or 
the  lateral  decubitus  is  assumed  in  sleep,  and  the  radial  nerve  of 
the  arm  placed  beneath  the  body  is  injured  by  pressure.  The 
deeper  the  sleep  the  less  will  the  inconvenience  of  a  given  posture 
be  appreciated^  and  the  greater,  therefore,  is  the  danger  of  press- 
ure-paralvsis.  Laborers  who  take  a  midday  nap  in  tlieir  work- 
places, and  drunkards,  are  therefore  attacked  by  sleep-paralysis 
with  particular  frequency.  Another  important  variety  of  trau- 
matic paralysis  of  the  radial  nerve  is  known  as  crutch-palsy. 
This  develops  at  times  even  Mithin  a  few  hours  after  the  use  of 
an  unsuitable  crutcli,  particularly  if  this  be  too  short  or  too  long, 
or  unpadded,  and  is  supplied  with  unsuitable  supports  for  the 
hands.  Of  all  the  nerves  of  the  arm,  the  radial  in  particular  is 
peculiarly  exposed  to  the  danger  of  compression  by  a  crutcli  on 
account  of  its  posterior  situation  in  the  axilla. 

A  few  other  varieties^  of  traumatic  radial  parali/sis  may  be  mentioned. 
Radial  paraly^^is  after  shackling  of  the  upper  arm  has  been  designated 
prisoners^  palsy.  Coaclrrnen's  palsy  has  been  observed  in  a  number  of  in- 
stances in  Russian  coachmen  who  have  wrapped  the  horses'  reins  too  firmly 
about  the  upper  arms,  and  have  then,  usually  in  a  drunken  state,  fallen 
asleep.  A  bandage-palsy  also  has  been  described  by  Russian  physicians, 
occurring  in  infants  when  the  arms  are  too  firmly  bandaged  to  the  trunk, 
and  the  infants  are.  besides,  permitted  to  lie  upon  one  side  of  the  body  for 
too  long  a  time.  Water-carriers'  palsy  of  Rennes  arises  from  the  carrying 
of  heavy  water-jugs,  through  the  handles  of  which  the  upper  arras  are 
passed,  "the  vessels  being  co'mpressed  against  the  abdomen.     In  the  same 


PARALYSIS  OF  THE  RADIAL  NERVE 


493 


way  the  carrj'ing  of  heavy  bundles  by  means  of  straps  or  ropes  wound  about 
the  upper  arms  may  give  rise  to  radial  paralysis.  Under  some  conditions 
the  application  of  Esmarch's  rubber  tube  to  the  arm  is  followed  by  peripheral 
pressure-paralysis  of  the  radial  nerve,  and  an  improperly  applied  plaster- 
of-Paris  bandage  may  also  have  the  same  effect.  The  designation  narcosis- 
paralysis  has  been  applied  to  cases  of  radial  palsy  that  have  developed 
during  narcosis,  in  the  course  of  an  operation,  in  consequence  of  compres- 
sion of  the  radial  nerve  by  the  head  of  the  humerus  in  lifting  the  arm 
upward.  Naturally,  punctured,  incised,  contused,  and  gunshot  wounds  may 
cause  injury  and  paralysis  of  the  radial  nerve.  Occasionally  radial  paraly- 
sis develops  in  the  sequence  of  luxation  or  fracture  of  the  humerus.  In  the 
latter  event  the  radial  nerve  may  be  lacerated  and  paralyzed  by  the  ex- 
tremities of  the  fractured  bone,  or  it  may  be  surrounded  by  callus  and 
be  paralyzed  by  compression.  Examples  of  traumatic  radial  paralysis  could 
be  largely  multiplied.  Drummers'  pjaralysis  may  yet  be  mentioned,  involv- 
ing most  commonly  the  long  extensor  of  the  thumb  and  resulting  from 
over-use  of  the  muscles  in  beating  the  drum. 

Anatomic  Alterations. — Little  is  known  Avith  regard  to 
the  anatomic  alterations  attending  peripheral  radial  paralysis,  be- 
cause the  disorder  in  no  sense  is  dangerous  to  life.  In  a  case  of 
radial  paralysis  following  typhus  fever  neuritic  alterations  were 
found,  and  in  a  case  of  recent  lead-palsy  I  succeeded  in  finding 
throughout  the  entire  nervous  system  only  degenerative  atrophy 
of  the  fibers  of  the  radial  nerve. 

Symptoms  and  Diagnosis. — Individuals  with  radial  paral- 
ysis attract  attention  at  once  by  the  position  of  tlie  hand  and  the 
fingers.  When  the  arm  is  raised  vertically  the  hand  is  flexed 
upon  the  palm,  and  at  the  same  time  pronated.  The  thumb  is 
adducted  and  slightly  flexed,  and  the  remaining  fingers  likewise 
are  flexed  upon  the  palm  (Fig.  66).     If  the  patient  be  directed  to 


Fig.  66.— Position  of  the  fingers  and  the  hand  in  a  case  of  peripheral  radial  paralysis— 
sleep-paralysis ;  from  a  photograph  (personal  observation,  Zurich  clinic). 

practise  dorsal  flexion  with  the  paralyzed  hand,  this  will  be  found 
impossible  on  account  of  paralysis  of  the  radial  and  ulnar  extensors 
of  the  carpus.  As  a  result  of  paralysis  of  the  common  extensor 
of  the  fingers  the  patients  are  unable  to  perform  dorsal  flexion  of 
the  basal  phalanx  of  the  fingers.     Extension  of  the  fingers  is  not 


494  NERVOUS  SYSTEM 

at  all  possible,  as  extension  of  the  second  and  third  phalanges, 
which  are  supplied  by  the  interosseous  muscles  (with  synchronous 
flexion  of  the  basal  phalanges),  can  take  place  only  if  the  basal 
phalanx  has  been  previously  flexed  upon  the  dorsum.  Extension 
of  the  lingers  can,  however,  be  effected  when  the  basal  phalanges 
have  been  passively  placed  in  dorsal  flexion.  Extension  of  the 
thumb  cannot  be  effected  because  the  long  and  short  extensors 
of  this  digit  are  paralyzed ;  abduction  also  is  greatly  limited 
in  consequence  of  paralysis  of  the  long  abductor  of  the  thumb. 
The  abolition  of  movement  in  the  fingers  and  the  thumb  causes 
great  difficulty  in  the  execution  of  all  fine  manipulations  (draw- 
ing, writing,  buttoning).  The  grasp  of  the  hand  is  extremely 
feeble,  because,  in  consequence  of  paralysis  of  the  extensors  of  the 
fingers,  the  points  of  attachment  for  the  flexors  are  not  sufficiently 
distant.  If  the  forearm  and  the  hand  are  placed  upon  a  horizontal 
support,  the  patient  will  be  unable  to  abduct  the  hand  toward  the 
radial  or  the  ulnar  aspect,  as  the  long  and  short  radial  extensors 
of  the  carpus  and  the  ulnar  extensor  of  the  carpus  are  paralyzed. 
AVhen,  however,  the  hand  is  held  in  the  dependent  posture  these 
movements  can  be  executed  by  the  corresponding  flexors.  Often 
radial  paralysis  is  limited  to  the  muscles  already  mentioned,  as 
the  nerve-filaments  for  the  long  and  short  supinators  and  the 
triceps  leave  the  trunk  of  the  nerve  quite  high  up,  and  are  fre- 
quently situated  above  the  point  of  injury.  Involvement  of  the 
short  supinator  in  radial  paralysis'  is  attended  with  inability  to 
execute  supination  of  the  forearm  when  this  member  is  held  in 
the  dependent  posture.  Paralysis  of  the  long  supinator  may  be 
recognized  by  the  absence  of  contraction  of  the  muscle  named 
when  resistance  is  offered  to  flexion  of  the  forearm  held  in  a  posi- 
tion midway  between  pronation  and  supination.  Paralysis  of  the 
triceps,  finally,  is  attended  Avith  inaljility  to  extend  the  flexed 
forearm,  or  to  offer  resistance  to  passive  flexion  of  the  forearm. 

The  alterations  in  electric  irritability  of  the  paralyzed  nerves 
and  muscles  vary  in  accordance  with  the  severity  of  the  palsy. 
In  the  presence  of  slight  and  moderately  severe  paralysis  the  elec- 
tric current  is  a  convenient  means  for  determining  the  seat  of  the 
paralysis,  for  if  the  course  of  the  radial  nerve  be  followed  with 
the  electrode  of  a  faradic  current  muscular  contractions  will  be 
wanting  above  the  seat  of  the  lesion,  and  will  be  observed  only 
below  this  point  on  stimulation  of  the  nerve.  After  the  paralysis 
has  existed  for  some  time  atrophy  from  icant  of  use  develops  in  the 
paralyzed  muscles. 

Although  the  radial  is  a  mixed  nerve,  sensory  disturbances  may 
be  wanting  in  a  case  of  radial  paralysis  because  the  sensory 
branches  are  given  off  from  the  trunk  of  the  nerve  at  so  high  a 
level  that  they  are  generally  situated  above  the  lesion,  or  because 
neighboring   nerves  assume  the  function  of  the  paralyzed  radial 


PARALYSIS  OF  THE  MEDIAN  NERVE  495 

branches.  When  sensory  disturbances  are  present  these  involve 
the  dorsal  aspect  of  the  upper  arm  (posterior  superior  cutaneous 
nerve),  that  of  the  forearm  (posterior  inferior  cutaneous  nerve), 
and  that  of  the  hand  and  the  fingers  between  the  thumb  and  the 
middle  of  the  middle  finger.  The  terminal  phalanges  naturally 
remain  unaffected,  as  these  are  supplied  with  cutaneous  branches 
by  the  median  nerve. 

Vasomotor  and  trophic  disorders  occur  but  exceptionally,  as,  for  instance, 
nodular  thickening  of  the  extensor-tendons  or  thickening  of  the  digital 
articulations. 

The  onset  of  paralysis  of  the  radial  nerve  is  often  sudden,  the 
patient  awaking  from  deep  sleep  therewith.  In  other  instances, 
however,  the  condition  is  preceded  by  prodromes — paresthesia,  such 
as  a  sense  of  contraction,  of  the  crawling  of  ants,  of  coldness  and 
stiffness,  and  the  like.  The  duration  of  radial  paralysis  generally 
is  exceedingly  long.  Even  mild  sleep-palsies  may  persist  from 
four  to  six  weeks.  Repeated  radial  paralysis  may  occur  in  laborers 
and  drunkards  if  compression  of  the  nerve  is  repeated  during 
sleep.  Plumbic  paralysis  of  the  radial  nerve  likewise  may  readily 
recur  if  the  individual  is  again  exposed  to  the  action  of  lead. 

PARALYSIS  OF  THE  MEDIAN  NERVE. 

etiology. — Peripheral  paralysis  of  the  median  nerve  is,  like 
that  of  the  radial  nerve,  generally  of  traumatic  origin.  The 
median  nerve  is  injured  with  particular  frequency  just  above  the 
wrist-joint,  upon  the  radial  aspect  of  the  palmar  surface  of  the 
forearm  by  incised  wounds,  as,  for  instance,  by  fragments  of  glass, 
while  injuries  of  the  trunk  of  the  nerve  in  the  internal  bicipital 
sulcus  are  much  less  common.  Nevertheless,  crutch-paralysis, 
prisoners^  'paralysis,  and  narcosis-paralysis  of  the  median  nerve, 
as  well  as  paralysis  in  consequence  of  luxation  and  fracture  of  the 
humerus,  have  been  observed.  At  times  median  paralysis  has  been 
observed  after  excessive  muscular  contraction.  In  this  group  is 
included  drummers'  paralysis,  which  involves  especially  the  flexor 
of  the  thumb,  and  naturally  much  more  commonly  the  long  exten- 
sor of  the  thumb  supplied  by  the  radial  nerve.  Refrigeratory  and 
infectious  paralysis  of  the  median  nerve  is  uncommon. 

Symptoms  and  Diagnosis. — The  extent  of  the  paralysis 
naturally  depends  upon  the  seat  of  the  lesion.  If  the  median 
nerve  is  injured  just  above  the  wrist-joint,  the  muscles  of  the 
thenar  eminence  are  paralyzed,  with  the  exception  of  the  adductor 
of  the  thumb,  supplied  by  the  ulnar  nerve,  and  in  consequence  of 
loss  of  function  on  the  part  of  the  short  abductor  of  the  thumb, 
the  short  flexor  of  the  thumb,  the  opposing  muscle  of  the  thumb, 
the  power  of  abduction  and  flexion  of  the  thumb  is  partially  and 
the  opposing  action  of  the  thumb  is  wholly  abolished.     When 


496 


NERVOUS  SYSTEM 


the  paralysis  has  existed  for  some  time  atrophy  of  the  thenar  mus- 
cles takes  place.  As  the  action  of  the  abductor  of  the  thumb, 
supplied  by  the  ulnar  nerve,  preponderates,  the  thumb  becomes 
permanently  approximated  to  the  hand,  and  its  terminal  phalanx 
is  markedly  flexed  upon  the  dorsum  through  the  action  of  the 
long  and  short  extensors  of  the  thumb.  As  a  result  there 
develops  a  form  of  hand  that  has  been  designated  the  ape- 
hand.  There  are  paralyzed,  in  addition,  the  first  and  second 
lumbrical  muscles,  which  effect  palmar  flexion  of  the  second  and 
third  phalanges  of  the  index-finger  and  the  middle  finger,  with 
synchronous  dorsal  flexion  of  the  basal  phalanx.  The  sensibility 
of  the  skin  is  lost  upon  the  radial  aspect  of  the  palmar  surface  of 
the  hand  to  a  median  line  passing  through  the  fourth  finger.  Upon 
the  dorsal  aspect  of  the  finger  cutaneous  sensibility  is  wanting 


Fig.  67.— Claw-hand  following  paralysis  of  the  left  ulnar  nerve  as  the  result  of  a  punctured 
wound  ;  from  a  photograph  (personal  observation,  Zurich  clinic). 

in  the  terminal  phalanges  of  the  thumb  and  of  the  second  and 
third  fingers.  Not  rarely  trophic  alterations  occur,  particularly 
glossy  finger,  vesication  of  the  skin,  thickening  and  fracture  of  the 
nails.  A  lesion  in  the  course  of  the  internal  l)icipital  sulcus  causes 
paralysis  of  all  of  the  muscles  upon  the  palmar  surface  of  the  fore- 
arm, in  addition  to  the  muscles  already  named,  with  the  exception 
of  the  ulnar  flexor  of  the  carpus,  which  is  supplied  by  the  ulnar 
nerve.  The  patient  is,  therefore,  unable  to  flex  the  terminal  pha- 
lanx (paralysis  of  the  deep  flexor  of  the  digits)  and  the  second 
phalanx  (paralysis  of  the  superficial  flexor  of  the  digits).  This  is 
particularlv  noticeable  in  the  second  and  third  fingers,  and  less  so 
in  the  fourth  and  fifth,  as  the  deep  flexor  receives  besides  branches 
from  the  ulnar  nerve.  Palmar  flexion  of  the  hand  can  be  effected 
only  with  difficulty,  and  with  synchronous  abduction  toward  the 
ulna  (from  contraction  of  the  ulnar  flexor  of  the  carpus).  In  con- 
sequence of  paralysis  of  tlie  radial  flexor  of  the  carpus  abduction 
of  the  hand  toward  the  radius  is  impossible  if  the  hand  is  in  a 


PARALYSIS  OF  THE    ULNAE  NERVE  497 

position  of  palmar  flexion.  Paralysis  of  the  round  pronator  and 
of  the  quadrate  muscle  prevents  pronation  of  the  dependent  arm, 
while  with  the  forearm  flexed  the  long  supinator  (supplied  by  the 
radial  nerve)  will  efi:ect  .pronation  of  the  forearm. 

PARALYSIS  OF  THE  ULNAR  NERVK 

etiology. — Refrigeratory  and  infectious  par^alysis  of  the  ulnar 
nerve  is  uncommon.  The  condition  is  generally  dependent  upon 
traumatic  influences,  which  coincide  with  those  of  traumatic  radial 
paralysis.  Sleep-palsy,  crutch-palsy,  narcosis-palsy,  and  prisoners' 
palsy  involving  the  ulnar  nerve  have  been  observed.  At  times 
pressure-paralysis  of  the  ulnar  nerve  has  been  noted  in  certain 
artisans  (clockmakers,  glassworkers)  as  a  result  of  long-continued 
support  of  the  arm  upon  the  elbow. 

Symptoms  and  Diagnosis. — Paralysis  of  the  ulnar  nerve 
is  attended  with  paralysis  of  the  muscles  of  the  hypothenar  emi- 
nence (abductor,  flexor,  and  opposing  muscle  of  the  fifth  digit), 
and  consequently  the  little  finger  is  incapable  of  executing  the 
corresponding  movements.  Paralysis  of  those  portions  of  the  deep 
flexor  of  the  digits  passing  to  the  ring-finger  and  the  little  finger 
prevents  plantar  flexion  of  the  terminal  phalanx  of  these  fingers. 
Plantar  flexion  of  the  hand  is  impaired,  and  can  be  performed 
only  toward  the  radial  but  not  toward  the  ulnar  aspect  (paralysis 
of  the  ulnar  flexor  of  the  carpus).  The  interosseous  muscles  are 
paralyzed,  and  as  a  consequence  the  patients  are  unable  to  perform 
plantar  flexion  of  the  basal  phalanx  of  the  fingers,  and  at  the 
same  time  to  extend  the  other  two  phalanges.  In  the  presence 
of  paralysis  of  the  ulnar  nerve  the  third  and  fourth  lumbrical 
muscles  are  further  paralyzed.  In  consequence  extension  of  the 
basal  phalanx  with  synchronous  plantar  flexion  of  the  other  two 
phalanges  is  wanting.  Sensory  disturbances  are  present  on  the 
palmar  aspect  of  the  hand  toward  the  ulna  from  a  median  line 
passing  through  the  ring-finger.  On  the  dorsal  surface  of  the 
hand  and  the  fingers  the  sensory  disturbance  extends  to  a  median 
line  passing  through  the  middle  finger  and  upon  the  ulnar  side 
of  this  line. 

After  the  paralysis  has  existed  for  some  time  atrophy  of  the 
paralyzed  muscles  takes  place  from  disuse.  This  is  appreciable 
particularly  in  the  muscles  of  the  hypothenar  eminence,  which 
presents  a  thin  and  flattened  appearance,  and  in  the  interosseous 
spaces,  which  present  unusually  deep  depressions.  At  times  a 
claw-hand  develops.  This  results  from  dorsal  hyperextension  of 
the  basal  phalanges  of  the  fingers  by  the  common  extensor  of  the 
digits,  while  in  consequence  of  paralysis  of  the  lumbrical  muscles 
the  flexors  of  the  fingers  cause  such  marked  palmar  flexion  of  the 
other  two  phalanges  that  at  times  the  nails  are  dug  into  the  palm 

32 


498  NERVOUS  SYSTEM 

of  the  hand.  As  the  first  and  third  himbrical  muscles  are  not 
involved  in  paralysis  of  the  ulnar  nerve,  the  claw-position  is  gen- 
erally more  pronounced  in  the  fourth  and  fifth  fingers  (Fig.  67). 

PARALYSIS   OF  THE  MUSCULOCUTANEOUS  NERVE. 

Paralysis  of  the  musculocutaneous  nerve  occurs  with  extreme 
rarity.  Paralysis  of  the  biceps  of  the  arm  is  most  commonly 
attended  with  loss  of  flexion  of  the  forearm  or  with  incomplete 
flexion  in  pronation  from  the  action  of  the  long  supinator  supplied 
by  the  radial  nerve. 

PARALYSIS  OF  THE  AXILLARY  NERVE. 

!^tiolog3''. — Paralysis  of  the  axillary  nerve  is  most  commonly 
of  traumatic  origin  (fall,  blow,  contusion  of  the  shoulder,  pressure 
by  a  crutch,  luxation  or  fracture  of  the  head  of  the  humerus). 
At  times  it  occurs  as  a  complication  of  inflammation  of  the  shoulder- 
joint,  perhaps  from  extension  of  the  inflammatory  process  to  the 
nerve.  Refrigeratory  and  toxic  paralysis  of  the  axillary  nerve 
(lead-poisoning,  diabetes  mellitus)  are  also  known. 

Symptoms  and  Diagnosis. — Paralysis  of  the  axillary  nerve 
is  attended  with  paralysis  of  the  deltoid  muscle.  Although  the 
axillary  nerve  sends  fibers  to  the  small  round  muscle,  no  disturb- 
ance of  function  is  observed  in  this  muscle,  as  it  receives  nerve- 
fibers  also  from  the  suprascapular  nerve.  \^  hen  the  deltoid  muscle 
is  paralyzed  the  patient  is  unable  to  elevate  the  arm  to  the  hori- 
zontal level.  The  muscle  undergoes  gradual  atrophy,  the  shoulder 
becomes  flattened  and  thin,  and  a  flail-joint  develops  at  the  shoul- 
der, in  consequence  of  the  traction  of  the  arm  and  the  deficient 
resistance  of  the  paralyzed  deltoid  muscle.  Sensory  disturbances 
may  be  present  upon  the  upper,  outer,  and  posterior  aspect  of  the 
arm. 

COMBINED  PARALYSIS  OF  THE  NERVES  OF  THE 
ARM  AND  THE  BRACHIAL  PLEXUS. 

By  combined  paralysis  of  the  nerves  of  the  arm  is  understood 
simultaneous  paralysis  of  several  nerves  of  this  member.  The  cause 
may  be  situated  in  the  upper  arm  or  the  forearm  or  in  the  brachial 
plexus.  The  last  situation  is  particularly  adapted  for  the  develop- 
ment of  combined  paralysis  of  the  nerves  of  tlie  arm,  because  here 
the  paths  for  the  various  nerves  to  the  arm  lie  so  closely  together 
that  even  a  small  lesion  is  capable  of  injuring  several  nerves  at  the 
same  time.  Constrictions  of  the  arm,  fractures,  luxations,  and  the 
pressure  of  a  crutch  are  well  adapted  to  injure  several  nerves  of 
the  arm  at  the  .same  time  in  their  course  through  the  member. 


PARALYSIS  OF  THE  NERVES  OF  THE  ARM  499 

Paralysis  of  the  brachial  plexus  also  is  generally  of  traumatic 
origin,  and  occurs  particularly  in  consequence  of  pressure  in  asso- 
ciation with  luxation  of  the  humerus,  dislocation  or  fractures  of 
the  clavicle,  and  neoplasms  of  the  neck.  At  times  it  has  been 
observed  to  set  in  abruptly,  in  an  apoplectifonii  manner,  spon- 
taneously, or  after  excessive  strain.  On  post-mortem  examination 
hemorrhage  into  the  brachial  plexus  has  been  observed  in  a 
number  of  instances.  In  all  cases  of  brachial  paralysis  motor 
disturbances  invariably  preponderate ;  sensibility  may  be  wholly 
unaltered.  In  accordance  with  the  seat  of  the  lesion  several  varie- 
ties of  paralysis  of  the  brachial  plexus  can  be  distinguished, 
namely,  an  upper,  a  lower,  and  a  mixed  variety,  the  last  including 
the  manifestations  of  the  other  two. 

The  upper  variety  of  paralysis  of  the  bracMal  plexus  involves 
the  fifth  and  sixth  cervical  nerve-roots.  It  includes  ErVs  j?aral- 
ysis  of  the  brachial  j)lexus,  which  is  attended  with  paralysis  of  the 
deltoid,  the  biceps,  the  internal  brachial,  and  the  long  supinator, 
and  also  at  times  of  the  supraspinous,  infraspinous,  and  short 
supinator.  Erb  showed  that  two  or  three  centimeters  above  the 
clavicle,  at  the  level  of  the  transverse  process  of  the  sixth  cervical 
vertebra,  just  behind  the  external  border  of  the  sternomastoid 
muscle  there  is  a  point — Erb's  supraclavicular  point — con-espond- 
ing  to  the  fifth  and  sixth  cervical  nerve-roots,  electric  stimulation 
of  which  induces  contraction  of  the  muscles  involved  in  Erb's 
paralysis  of  the  brachial  plexus. 

Parturitional  or  obstetric  paralysis  also  belongs  in  this  category. 
This  is  observed  in  the  newborn  when  during  labor  it  has  been 
necessary  to  free  the  arms  or  apply  the  fingers  over  the  clavicles, 
or  introduce  a  hook  or  the  fingers  into  the  axillary  cavity.  Ob- 
stetric palsy  may  result  also  from  slipping  of  the  forceps  and 
pressure  upon  the  brachial  plexus.  Generally,  in  addition  to  the 
paralysis  there  is  found  luxation  or  fracture  of  the  humerus  or 
fracture  of  the  clavicle  or  of  the  scapula.  The  muscles  involved 
are  the  same  as  those  that  suffer  in  Erb's  palsy.  Recovery  is  not 
impossible. 

The  lower  variety  of  paralysis  of  the  brachial  plexus  involves  the 
distribution  of  the  eighth  cervical  and  the  first  dorsal  nerve.  The 
muscles  paralyzed  include  those  of  the  thenar  and  hypothenar 
eminences,  the  interosseous,  and  at  times  also  some  of  the  flexors 
of  the  forearm.  Oculopupillary  symptoms  (contraction  of  the 
pupil,  narrowing  of  the  palpebral  fissure,  retraction  of  the  eye- 
ball) will  be  especially  conspicuous.  These  depend  upon  the  cir- 
cumstance that  the  communicating  branch  of  the  first  dorsal  nerve 
transmits  oculopupillary  fibers  from  the  cervical  cord  to  the  path 
for  the  cervical  sympathetic.  Sensory  disturbances  may  be  ob- 
served especially  in  the  distribution  of  the  median  and  the  ulnar 
nerve  and  on  the  inner  aspect  of  the  upper  arm.  ' 


500 


NERVOUS  SYSTEM 


PERIPHERAL  PARALYSIS  OF  THE  SCAPULAR 

MUSCLES. 

PARALYSIS  OF  THE  SERRATE  MUSCLE. 

Ktiology. — The  greater  untericn-  serrate  niusele  receives  fibers 
from  the  lung  thoracic  nerve,  a  branch  of  the  brachial  plexus. 
Peripheral  paralysis  of  the  serrate  muscle  is  not  unconmion,  as 
the  nerve  pursues  a  superficial  and  long  course  on  the  side  of  the 
neck  and  the  lateral  aspect  of  the  chest.  Most  commonly  paralysis 
of  the  serrate  muscle  is  of  traumatic  origin,  as,  for  instance,  from 


Fig.  68.— Position  of  the  scapula  with  the  arm  dependent  in  a  case  of  paralysis  of  the 
right  serrate  muscle  in  consccjuence  of  muscular  over-exertion  in  a  weaver  for  fourteen 
years  (personal  observation,  Zurich  clinic). 

punctured  or  incised  wounds  of  the  neck,  or  from  the  carrying  of 
heavy  weights  upon  the  shoulder.  At  times  paralysis  of  the  ser- 
rate muscle  results  from  muscular  over-exertion.  I  have  seen  such  a 
condition  after  the  mowintr  of  hnv  and  after  lono--continued  weavino;. 
Paralysis  of  the  serrate  muscle  has  been  observed  also  after  too 
long-continued  planing  and  sawing.  Infectious  paralysis  of  the 
serrate  muscle  has  been  reported  in  the  sequence  of  typhoid  fever, 
diphtheria,  erysipelas,  and  other  infectious  diseases.  Befrigeratory 
jiaralysis  of  the  serrate  muscle  is  also  known.     Almost  always  the 


PERIPHERAL  PARALYSIS  OF  THE  SCAPULAR  MUSCLES  501 

condition  occurs  in  adults,  and  more  commonly  in  men  than  in 
women. 

Symptoms  and  Diagnosis. — Paralysis  of  the  serrate  muscle 
is  attended  with  an  abnormal  position  of  the  scapula,  which  is 
apparent  even  with  the  arm  at  rest  and  dependent,  but  becomes 
more  conspicuous  when  the  arm  is  held  in  front  of  the  body  or  is 
elevated  vertically.    When  the  arm  is  dependent  the  inferior  angle 


///^'  -^"^   ^  ^^  III  ^\: 

Fig.  69.— The  same  patient  as  shown  in  Fig.  68,  with  the  arm  elevated  in  front. 


of  the  scapula  is  removed  from  the  dorsal  aspect  of  the  chest  (from 
preponderant  action  of  the  biceps,  the  lesser  pectoral,  and  the 
coracobrachial).  The  inner  border  of  the  scapula  is  more  closely 
approximated  to  the  vertebral  column  upon  the  diseased  than  upon 
the  healthy  side  (from  preponderant  action  of  the  rhomboid  and 
the  trapezius),  and  the  inferior  angle  of  the  scapula  is  more  closely 
approximated  to  the  vertebral  column  than  the  upper  and  inner 
angle.    In  consequence,  the  inner  border  of  the  scapula  is  directed 


502 


NERVOUS  SYSTEM 


from  above  and  without  downward  and  inward.  The  entire  scapula 
occupies  a  higher  level  upon  the  diseased  than  upon  the  healthy 
side  (Fig.  68).  If  the  arm  is  raised  in  front  of  the  body,  the 
internal  border  of  the  scapula  becomes  so  greatly  removed  from 
the  dorsal  aspect  of  the  chest  that  the  hand  can  be  easily  inserted 
between  the  chest-wall  and  the  border  of  the  scapula  (Fig.  69). 
At  the  same  time  tiie  scapula  becomes  still  more  closely  approxi- 
mated to  the  vertebral  column.     This  approximation  becomes  the 


Fig.  70.— The  same  patient  as  shown  in  Figs.  68  and  6l>,  with  the  arms  elevated  vertically. 

greater  if  the  arm  is  raised  to  a  vertical  position  (Fig.  70).  Ele- 
vation of  the  arm  slowly  above  the  horizontal  level  is  possible 
only  with  difficulty,  and  can  be  effected  with  greater  ease  only  if 
the  scapula  has  previously  been  put  in  proper  position  by  the 
hands  and  is  there  held  during  the  act  of  elevating  the  arm.  All 
movements  of  the  arm  forward  (pushing,  crossing)  are  rendered 
difficult,  and  the  patient  is  unable  to  offi?r  any  resistance  to  retrac- 
tion of  the  scapula.     Gradually  the  serrate  muscle  may  undergo 


PERIPHERAL  PARALYSIS  OF  THE  SCAPULAR  MUSCLES  503 

atrophy  from  disuse,  the  thorax  becoming  flattened  on  its  lateral 
aspect  and  the  otherwise  readily  visible  serrations  of  the  muscle 
being  lost.  As  a  prodrome  of  paralysis  of  the  serrate  muscle,  pain 
at  times  appears  in  the  shoulder,  and  subsequently  may  be  replaced 
by  cutaneous  anesthesia.  Paralysis  of  the  serrate  muscle  is  gen- 
erally unilateral.  Traumatic  bilateral  serrate  paralysis  may  be 
observed  if  heavy  weights  are  carried  lirst  upon  one  shoulder  and, 
after  paralysis  lias  developed,  subsequently  upon  the  opposite 
shoulder,  or  if  at  first  one  of  the  muscles  and  then  the  other  is 
unduly  strained. 

PARALYSIS  OF  THE  GREATER  AND  LESSER  PECTORAL 

MUSCLES. 
The  greater  and  lesser  pectoral  muscles  are  supplied  by  the 
anterior  thoracic  nerve.  Paralysis  of  these  muscles  is  uncommon, 
and  is  characterized  by  impairment  of  adduction  of  the  upper 
arm  upon  the  paralyzed  side,  and  absence  of  muscular  elevation 
in  the  infraclavicular  region  on  attempted  adduction.  The  patient 
is  able  only  with  difficulty  to  place  the  hand  upon  the  healthy 
shoulder,  and  to  clap  the  hands.  Little  resistance  is  oifered  to 
passive  abduction  of  the  upper  arm.  Atrophy  of  the  paralyzed 
muscles  is  attended  with  the  development  of  a  marked  depression 
in  the  infraclavicular  region. 

PARALYSIS  OF  THE  RHOMBOID  AND  THE  ELEVATOR  OF 
THE  ANGLE  OF  THE  SCAPULA. 

The  rhomboid  and  the  elevator  of  the  angle  of  the  scapula  are 
supplied  by  the  dorsal  nerve  of  the  scapula  from  the  brachial 
plexus.  Derangement  of  function  appears  in  connection  with 
paralysis  of  the  muscles  named  only  when  the  trapezius  is  paral- 
yzed at  the  same  time.  Under  such  conditions  paralysis  of  the 
rhomboid  prevents  approximation  of  the  scapula  to  the  vertebral 
column,  while  paralysis  of  the  elevator  of  the  scapula  prevents 
movement  of  the  scapula  upward. 

PARALYSIS  OF  THE  BROAD  DORSAL  MUSCLE. 

Paralysis  of  the  broad  dorsal  muscle,  supplied  by  the  subscap- 
ular nerves  of  the  brachial  plexus,  is  attended  with  difficulty  in 
adduction  of  the  arm  to  the  chest,  but  particularly  in  the  move- 
ment of  the  arm  and  the  hand  toward  the  gluteal  region. 

PARALYSIS  OF  THE  INTERNAL  ROTATORS  OF  THE  ARM. 
The  internal  rotatcjrs  of  the  arm  include  the  subsca2)ular  and 
the  greater  round  muscle,  both  of  which  are  supplied  by  the  sub- 
scapular nerves  of  the  brachial  plexus.     When  the  muscles  named 
are  paralyzed  the  action  of  the  external  rotators  of  the  arm  (infra- 


504  NERVOUS  SYSTEM 

spinous,  lesser  round  muscle)  preponderates,  so  that  the  palmar 
aspect  of  the  arm  and  the  hand  is  directed  forward,  and  the  arm 
cannot  be  rotated  inward  on  request.  All  of  the  movements  of 
the  hand  directed  to  tlie  opposite  side  of  the  body  are,  therefore, 
rendered  difficult.  If  atrophy  of  the  subscapular  occurs,  crackling 
sounds  are  audible  on  movement  of  the  scapula,  but  these  are 
present  also  in  some  healthy  persons. 

PARALYSIS  OF  THE  EXTERNAL  ROTATORS  OF  THE  ARM. 

The  external  rotators  of  the  arm,  the  infraapiiioas  and  the 
lesser  round  muscle,  are  supplied  by  diiferent  nerves,  namely,  the 
infraspinous  by  the  suprascapular  and  the  lesser  round  by  the 
axillary.  Paralysis  of  both  muscles  is  attended  Avith  internal 
rotation  of  the  arm  from  preponderant  action  of  the  internal  rota- 
tors, so  that  the  ulnar  border  of  the  arm  is  directed  forward. 
External  rotation  of  the  arm  is  impossible.  When  the  infra- 
spinous muscle  upon  the  right  side  is  paralyzed  the  movements 
necessary  in  writing  and  sewing  are  greatly  interfered  with. 
Atrophy  of  the  infraspinous  muscle  gives  rise  to  a  depression  in 
the  infraspinous  fossa. 

PERIPHERAL  PARALYSIS  OF  THE  MUSCLES  OF 
THE  BAOC 

Paralysis  of  the  lumbar  extensor  muscles  is  attended  with  marked 
convex  curvature  of  the  vertebral  column  forward  in  standing — 
lordosis — a  vertical  line  through  the  dorsal  vertebrae  passing  far 
behind  the  sacral  promontory.  In  the  sitting  posture,  however, 
marked  h/pJwsis  develops  in  the  lumbar  region,  and  the  upper 
portion  of  the  body  inclines  so  far  forward  that  the  patient  is 
compelled  to  support  his  arms  upon  the  thighs  in  order  not  to 
fall  over.  In  the  dorsal  decubitus  the  kyphosis  disappears.  If 
the  patient  be  seated  upon  the  floor  and  attempts  to  arise,  he  will 
slowly  climb  up  upon  his  own  extremities  with  rotatory  move- 
ments of  the  body.  The  waddling,  duck-like  walk  is,  further, 
peculiar.  Paralysis  of  the  extensors  of  the  back  is  attended  with 
paralytic  kyphosis  in  the  standing  posture,  which  disappears  in 
the  dorsal  decubitus.  Unilateral  paralysis  will  give  rise  to  para- 
lytic scoliosis.  Paralysis  of  the  extensors  of  the  neck  is  attended 
with  drooping  forward  of  the  head. 

PERIPHERAL  PARALYSIS  OF  THE  ABDOMINAL 
MUSCLES. 

Unilateral  paralysis  of  the  abdominal  7nuscles  is  attended  with 
retraction  of  the  umbilicus  toward  the  healthy  side  with  each 
expiration.     Bilateral  jMralysis  of  the  abdominal  muscles  prevents 


PERIPHERAL  PARALYSIS  OF  THE  OBTURATOR  NERVE   505 

all  expulsive  and  expiratory  movements  (cough,  sneezing,  strain- 
ing at  stool).  The  hand  applied  to  the  abdominal  wall  fails  to 
detect  contraction  during  the  movements  named.  Change  from 
the  recumbent  to  the  sitting  posture  is  possible  only  with  the  aid 
of  the  arms.  In  standing,  the  abdomen  protrudes  greatly  for- 
ward. In  walking,  the  upper  portion  of  the  body  is  bent  forward, 
and  the  lumbar  portion  of  the  vertebral  column  is  the  seat  of 
lordosis.  A  vertical  line  through  the  cervical  vertebrae  will  pass 
in  front  of  the  sacral  promontory,  as  the  pelvis  is  bent  greatly 
forward.  Simultaneous  paralysis  of  the  abdominal  muscles  and 
the  muscles  of  the  back  is  attended  with  impossibility  of  maintain- 
ing the  upright  posture. 

PERIPHERAL  PARALYSIS  OF  THE  CRURAL  NERVE, 

Paralysis  of  the  crural  nerve  of  refrigeratory,  toxic,  or  infec- 
tious origin  is  uncommon ;  most  frequently  it  is  of  traumatic 
origin.  The  causes  may  reside  within  the  vertebral  canal  (hemor- 
rhage) or  consist  in  disease  of  the  vertebral  column  (fracture, 
tuberculosis,  new-growth)  or  inflammation  or  a  new-growth  in 
the  true  pelvis.  Aneurysms  of  the  femoral  artery  and  punctured 
and  incised  wounds  may  also  be  mentioned  as  causes  for  the  paral- 
ysis. Paralysis  of  the  iliopsoas  muscle  prevents  flexion  of  the 
thigh  upon  the  abdomen,  and  paralysis  of  the  quadriceps  extensor 
of  the  thigh  renders  impossible  extension  of  the  flexed  thigh  or 
resistance  to  passive  flexion.  Naturally,  the  patellar  tendon-reflex 
is  wanting.  Such  sensory  disturbances  as  may  be  present  are  dis- 
tributed upon  the  anterior  and  inner  aspect  of  the  thigh,  and  in 
the  course  of  the  greater  saphenous  nerve,  also  along  the  inner 
aspect  of  the  leg  and  the  inner  border  of  the  foot.  Atrophy  of 
the  paralyzed  muscles  from  disuse  is  attended  with  wasting  of 
the  thigh  upon  its  anterior  aspect.  The  paralysis  of  the  muscles 
named  is  attended  further  with  disturbances  in  walking  and  in 
changing  from  the  sitting  to  the  standing  posture. 

PERIPHERAL  PARALYSIS  OF  THE  OBTURATOR 

NERVE. 

Peripheral  paralysis  of  the  obturator  may  result  from  the  same 
causes  as  paralysis  of  the  crural  nerve,  and  at  times  both  nerves 
are  paralyzed  simultaneously.  Occasionally  paralysis  of  the  ob- 
turator nerve  is  observed  after  difficult  labor  or  after  incarcera- 
tion of  an  obturator  hernia.  The  abductors  of  the  thigh  particu- 
larly are  paralyzed,  so  that  the  patient  is  unable  to  move  the 
abducted  member  to  the  middle  line,  or  to  throw  it  over  the 
healthy  member  in  the  recumbent  or  sitting  posture.  In  conse- 
quence of  paralysis  of  the  external  obturator,  external  rotation  of 


506  NERVOUS  SYSTEM 

tlie  lower  extremity  also  is  embarrassed.     Sensory  disturbances 
may  be  present  upon  the  internal  aspect  of  the  thigh. 

PERIPHERAL  PARALYSIS  OF  THE  GLUTEAL  NERVES, 

Paralysis  of  the  gluteal  nerves  is  attended  with  difficulty  in 
rotation  of  the  thigJi  botli  inward  (middle  and  lesser  gluteus,  inter- 
nal obturator,  tensor  of  the  broad  fascia)  and  outward  (greater 
gluteus).  Abduction  of  the  leg  is  interfered  with  (greater  and  mid- 
dle gluteus).  Walking,  particularly  ascending  stairs,  is  rendered 
difficult,  because  the  iliopsoas  and  the  greater  gluteus  are  com- 
pelled to  fix  the  trunk  upon  the  thigh  and  to  maintain  the  equi- 
librium, and  the  action  of  the  iliopsoas  preponderates  in  the  pres- 
ence of  paralysis  of  the  greater  gluteus.  In  consequence  of  paral- 
ysis of  the  greater  gluteus  change  from  flexion  of  the  body  for- 
ward to  the  upright  posture  is  impossible.  Atrophy  of  the  gluteal 
muscles  from  disuse  is  characterized  by  flattening  and  w^asting  of 
the  buttocks. 

PERIPHERAL  PARALYSIS  OF  THE  SCIATIC  NERVK 

Ktiology. — Peripheral  paralysis  of  the  sciatic  nerve  may  in- 
volve the  trunk  of  the  nerve  or  individual  branches.  In  the  lat- 
ter event  peroneal  is  more  common  than  tibial  paralysis.  The 
tntnh  of  the  sciatic  nerve  often  suffijrs  from  traumatism,  "while 
refrigeratory,  infectious,  and  toxic  paralyses  are  observed  much 
less  commonly.  The  trauuiatic  causes  are  approximately  tlie  same 
as  those  for  peripheral  paralysis  of  the  crural  nerve.  Isolated 
jialsies  of  the  peroneal  nerve  have  been  observed  in  a  number  of 
instances  in  laborers  compelled  to  occupy  a  stooping  posture  for  a 
long  time  in  their  work  (potato-pickers,  stone-setters,  asphalters). 

Symptoms  and  Diagnosis. — In  cases  of  paralysis  of  the 
trunk  of  the  sciatic  nerve  flexion  of  the  leg  upon  the  thigh  is  im- 
possible (paralysis  of  the  l)iceps  of  the  thigh,  the  semitendinosus, 
the  semimembranosus).  External  rotation  (internal  obturator, 
gemelli,  pyriform)  and  aljduction  of  the  thigh  also  are  restricted. 
In  walking  the  extremity  remains  straight  and  is  not  flexed  at  the 
knee-joint.  In  the  presence  of  peroneal  paralysis  the  tip  and  the 
outer  border  of  the  foot  are  directed  downward  (pes  varo-equinus). 
In  walking  the  patient  must  lift  the  foot  high,  in  order  to  avoid 
scraping  the  floor  with  the  toes,  and  the  foot  is  brought  down  upon 
its  outer  border.  Dorsal  flexion  of  the  foot  and  the  toes  is  im- 
possible. Paralysis  of  the  tibial  nerve  prevents  plantar  flexion  of 
the  foot  and  the  toes,  and,  from  the  preponderant  action  of  the 
antagonists,  gradually  gives  rise  to  pes  calcaneus — club-foot.  In 
addition,  in  consequence  of  paralysis  of  the  posterior  tibial  muscle, 
abduction  of  the  foot  is  greatly  impaired  (posterior  tibial). 


MOTOR  TRIGEMINAL  SPASM.  507 

PERIODIC  PARALYSIS. 

The  designation  periodic  paralysis  has  been  applied  to  a  condi- 
tion in  which  persons  are  periodically  paralyzed  for  hours  in  the 
upper  and  lower  extremities,  and  at  tin:ies  also  in  a  number  of 
cerebral  nerves.  The  electric  irritability  of  the  paralyzed  nerves 
and  muscles  is  greatly  diminished,  or  even  at  times .  abolished. 
The  disease  is  hereditary.  It  has  been  thought  to  be  dependent 
upon  auto-intoxication. 

SPASMODIC  DISORDERS  OF  MOTOR  NERVES 
(HYPERKINESIS). 

Muscular  spasm  may  be  either  tonic  or  clonic.  With  tonic 
spasm  there  is  persistent  contraction  of  the  muscle,  which  may  re- 
main shortened  and  hard  for  hours  and  at  times  for  days.  Clouic 
spasm  is  attended  with  intermittent  muscular  contractions  usually 
appreciable  to  the  eye  and  the  applied  hand  and  capable  of  enu- 
meration. If  tonic  muscular  spasms  are  attended  with  pain,  they 
are  designated  cramps. 

MOTOR  TRIGEMINAL  SPASM, 

Motor  trigeminal  spasm  is  known  also  as  masticatory  spasm,  be- 
cause it  involves  the  muscles  of  mastication.  Tonic  spasm  of  the 
muscles  of  mastication  gives  rise  to  the  clinical  picture  of  trismus  or 
lockjaw.  The  jaws  are  clinched  tightly  and  the  patient  is  unable 
to  separate  them,  speaking  through  the  teeth,  and  the  contracted 
temporals  and  masseters  are  usually  visible  and  palpable  beneath 
the  skin  as  muscular  masses  of  board-like  hardness.  Naturally, 
persistent  trismus  is  attended  with  the  danger  of  starvation,  so 
that  it  becomes  necessary  for  purposes  of  artificial  nutrition  to  in- 
troduce an  esophageal  tube  between  the  teeth  or  into  the  nose,  or  to 
administer  nutrient  enemata.  Most  commonly  trismus  results  in 
consequence  of  reflex  irritation  from  the  irruption  of  teeth  and 
periostitis  of  the  lower  jaw.  It  is  quite  a  constant  symptom  of 
tetanus,  although  here  it  is  probably  due  to  central  irritation. 
The  best-known  examples  of  clonic  spasm  of  the  muscles  of  masti- 
cation are  the  chattering  of  the  teeth  on  exposure  to  cold  and  to 
emotional  influences,  and  the  grinding  of  the  teeth  in  cases  of  men- 
ingitis and  in  teething  children.  In  the  first  event  particularly 
the  masseters  and  the  temporals  are  involved,  in  the  latter  the 
pterygoids.  At  times  spasm  of  the  muscles  of  mastication  is  asso- 
ciated with  trigeminal  neuralgia. 

In  the  treatment  an  attempt  will  be  made  first  to  remove  the 
causative  factors.    In  addition,  subcutaneous  injections  of  morphin. 


508  NERVOUS  SYSTEM 

applications  of  the  galvanic  and  the  faradic  current,  and  in  the 
presence  of  trismus  even  gradual  separation  of  the  jaws  by  the 
introduction  of  wedges. 

SPASM  OF  THE   MUSCLES  OF  THE  FACE 
(PSOROSPASM). 

Symptoms,  Diagnosis,  and  Prognosis. — ]Most  commonly 
clonic  spasm  of  the  muscles  of  the  face  is  ol)served.  If  all  of  these 
7nuscl('s  are  involved,  the  condition  is  generally  unilateral.  Spon- 
taneously and  particularly  on  emotional  disturbance  active  con- 
tractions take  place  in  the  various  muscles  of  the  face,  giving  rise 
to  marked  and  disfiguring  grimaces.  Wrinkling  of  the  foreiiead, 
blinking  of  the  eyes,  distortion  of  the  cheeks,  puckering  of  the 
lips,  and  dilatation  of  the  mouth  alternate  irregularly  with  one 
another,  and  the  appearance  resembles  the  distortions  of  the  facial 
muscles  induced  by  faradization  of  the  facial  nerve.  At  times 
pressure -points  are  discovered  over  the  supraorbital  or  the  infra- 
orbital nerve,  the  spinous  or  the  transverse  processes  of  the  cer- 
vical vertebrae,  the  condyles  of  the  radius  or  the  ulna,  the  mucous 
membrane  of  the  buccal  or  the  nasal  cavity,  pressure  upon  which 
causes  cessation  of  the  spasm.  The  number  of  paroxysms  of 
spasm  varies  ;  often  they  are  repeated  within  a  few  minutes.  The 
individual  paroxysm  is  of  widely  varying  intensity,  extent,  and 
duration.  At  times  there  is  but  a  transitory,  lightning-like  con- 
traction of  the  muscles  of  the  face.  The  stapedius,  the  muscles 
of  the  palate,  and  the  salivary  secretory  nerves  do  not,  as  a  rule, 
participate  in  the  clonic  muscular  spasm.  The  contractions 
usually  cease  during  sleep,  altliough  I  have  ol)served  them  to  per- 
sist in  cases  of  cerebral  hemi])legia.  The  disorder  is  annoying, 
but  not  dangerous.  Not  rarely  it  persists  throughout  life.  Re- 
covery can  be  expected  only  when  the  causative  factors  are  dis- 
coverable and  are  capable  of  removal. 

Partial  clonic  spasm  of  the  muscles  of  the  face  occurs  also  in 
healthy  persons  following  great  mental  excitement,  as,  for  instance, 
involuntary  wrinkling  of  the  forehead,  the  play  of  the  alfe  of  the 
nose,  and  the  twitching  of  the  lips.  The  best-known  of  the 
varieties  of  partial  clonic  spasm  of  the  facial  muscles  is  clonic 
spasm  of  the  sphincter  of  the  eyelids — nictitation — which  is 
observed  with  particular  frequency  in  association  with  diseases  of 
the  eyes  themselves. 

Tonic  spasm  of  the  facial  muscles  is  most  commonly  partial,  and 
involves  with  preference  the  sphincters  of  the  eyelids.  With  the 
onset  of  such  spasm — blepharospasm — the  eyelids  snap  together 
like  the  lid  of  a  chest,  and  remain  closed  until  the  attack  termi- 
nates. The  duration  of  an  attack  varies  between  minutes,  hours, 
and  weeks.     Naturally,  the   patient  is  unable  to  see  during  the 


SPASM  OF  THE  MUSCLES  OF  THE  FACE  509 

attack,  and  if  this  occur  on  the  crowded  street  the  patient  may  be 
exposed  to  serious  danger.  It  is  noteworthy  that  at  times  points 
are  discoverable  upon  the  body,  as,  for  instance,  over  the  supra- 
orbital and  infraorbital  nerves,  the  cervical  vertebrae  or  elsewhere, 
on  pressure  upon  which  the  muscular  spasm  ceases  and  the  closed 
eyelids  separate.  The  disorder  may  be  extremely  obstinate  and 
persist  throughout  the  whole  of  life. 

!^tiology. — Spasm  of  the  facial  muscles  is  observed  with 
particular  frequency  in  nervous  persons.  At  times  the  disorder  is 
inherited,  although  some  members  of  the  family  perhaps  will  not 
suffer  from  spasm  of  the  facial  muscles,  but  from  certain  central 
neuroses  (hysteria,  neurasthenia,  epilepsy,  chorea,  psychopathy, 
etc.).  At  times  the  disorder  is  due  to  traumatism.  Thus,  it  has 
been  observed  to  develop  in  the  sequence  of  contusion  of  the 
trunk  of  the  facial  nerve,  as  a  result  of  the  pressure  exerted  by 
enlarged  lymphatic  glands  or  by  an  aneurysm  of  a  cerebral  artery. 
Frequently  it  occurs  in  consequence  of  reflex  irritation,  as,  for 
instance,  in  association  with  trigeminal  neuralgia,  and  diseases  of 
the  eyes  and  the  teeth.  It  has  been  observed  also  in  women  with 
disease  of  the  uterus  or  the  ovaries,  and  in  persons  with  intestinal 
worms.  In  children  the  habit  of  imitation  plays  an  important 
part ;  that  is,  previously  healthy  persons  who  are  brought  much 
in  contact  with  those  presenting  facial  spasm  are  attacked  by  the 
same  disorder.  Also  originally  voluntary  grimaces  may  gradually 
be  converted  into  involuntary  facial  spasm.  Experience  has  shown 
that  men  are  attacked  by  spasm  of  the  facial  muscles  more  com- 
monly than  women.  The  disorder  occurs  less  commonly  in  child- 
hood. 

Anatomic  Alterations. — But  little  is  known  with  regard 
to  the  anatomic  alterations  attending  spasm  of  the  facial  muscles. 
In  any  event  the  latter  may  occur  in  the  absence  of  any  change 
in  the  fibers  of  the  facial  nerve,  so  that  the  disturbances  present 
must  be  of  a  purely  functional  nature. 

Treatment. — In  the  first  place,  an  effort  should  be  made  to 
remove  any  causative  factors  present — causal  therapy — considera- 
tion being  given  particularly  to  facial  spasm  of  reflex  origin.  The 
rapidity  with  which  the  spasms  cease  after  removal  of  the  causative 
conditions  is  often  surprising.  Unfortunately,  such  cases  are  the 
less  common.  As  a  rule,  one  is  compelled  to  resort  to  symptomatic 
treatment.  In  nervous  persons  success  may  be  attained  by  means 
of  2i  judicious  mode  of  life  and  the  administration  of  nervines,  par- 
ticularly hromids.  Narcotics  also,  particularly  subcutaneous  injec- 
tions of  morphin,  have  been  largely  used.  At  times  psychic  treat- 
ment will  be  indicated,  particularly  in  children,  li  jyressure-points 
can  be  demonstrated,  applications  of  the  galvanic  current  through 
the  anode  should  be  made  to  them.  Recourse  has  been  had  also 
to  nerve-section  (neurotomy),  nerve-excision  (neurectomy),  and  nerve- 


510  NERVOUS  SYSTEM 

stretching ;  but  generally  the  twitchings  cease  only  so  long  as  the 
facial  paralysis  persists,  generally  recurring  with  the  disappear- 
ance of  the  paralysis. 

SPINAL  ACCESSORY  SPASM. 

Wliat  has  been  said  concerning  spasm  of  the  facial  muscles  is 
applicable  also  to  the  causes  of  spinal  accessory  spasm.  At  times 
disease  of  the  cervical  vertebrce  is  responsible  for  the  disorder.  In 
children  it  has  been  observed  at  the  period  of  dentition.  Unilateral 
clonic  sjmsm  of  one  sternomastoid  is  attended  with  periodic  twitch- 
ing movements  of  the  head,  the  face  and  the  chin  being  rotated 
toward  the  healthy  side,  the  chin  elevated,  and  the  occiput  re- 
tracted. Unilateral  tonic  spasm  of  the  sternomastoid  is  attended 
with  persistence  of  this  position  during  the  attack  and  immobility 
of  the  head — spasmodic  torticollis.  Bilateral  clonic  spasm  of  the 
sternomastoid  is  attended  with  various  manifestations,  accordingly 
as  the  spasmodic  muscular  contractions  of  the  sternomastoid  occur 
alternately  or  synchronously.  In  the  first  instance  the  head  is  in- 
volved in  rotatory  movements,  in  the  latter  in  nodding  movement. 
Bilateral  tonic  spasm  of  the  sternomastoid  is  attended  with  retrac- 
tion of  the  head. 

In  addition  to  the  sternomastoid,  the  trapezius  also  is  involved 
in  cases  of  accessory  spasm.  Unilateral  clonic  spasm  of  the  tra- 
pezius is  attended  with  elevation  of  the  scapula  and  retraction 
of  'the  head.  The  symptoms  of  bilateral  clonic  as  well  as  of 
tonic  spasm  of  the  trapezius  may  be  understood  without  further 
description.  A  striking  and  varying  picture  of  alterations  in  the 
movements  of  the  head  and  the  shoulder  results  when  both  the 
sternomastoid  and  the  trapezius  are  involved  in  the  spasm, 
although  it  is  easy  to  separate  the  picture  into  its  individual 
constituents.  With  regard  to  the  prognosis  and  the  treatment, 
the  same  statements  are  applicable  as  were  made  concerning  spasm 
of  the  facial  muscles. 


HYPOGLOSSAL  SPASM. 

Hvpoglossal  spasm  is  attended  with  spasm^  of  the  tongue — 
glossospasm — and  accordingly  as  this  occurs  in  the  act  of  chewing 
or  of  speaking  a  distinction  is  made  between  m a sticatoi'i/  and  artic- 
idatorj/  spasm  of  the  tongue.  The  spasm  may  be  clonic  or  tonic 
and  unilateral  or  bilateral.  The  disorder  can  be  readily  recog- 
nized, and  attacks  particularly  hysterical  and  nervous  persons. 
In  accordance  with  the  character  of  the  spasm,  either  the  mastica- 
tory or  the  articulatory  movements  are  interfered  with.  If  the 
tongue  is  retracted  for  a  considerable  length  of  time,  danger  of 
suffocation  may  arise. 


SPASM  OF  THE  DIAPHRAGM 


511 


SPASM  OF  THE  CERVICAL  AND  SCAPULAR  MUSCLES. 

Spasm  of  the  Inferior  Oblique  Muscle  of  the  Head. — This  muscle 
rotates  the  head  in  the  horizontal  level,  without  elevating  or 
depressing  the  chin.  If  the 
disorder  be  unilateral  and 
clonic,  the  head  is  rotated 
horizontally  toward  the  dis- 
eased side,  while  in  the 
presence  of  bilateral  alter- 
nating muscular  spasm  ro- 
tatory movements  of  the 
head  from  side  to  side 
occur — rotatory  spasm  or 
tic.  Unilateral  tonic  spasm 
keeps  the  head  constantly 
turned  toward  one  side,  and 
resistance  is  encountered 
when  an  attempt  is  made 
to  restore  the  head  to  its 
normal  position. 

Spasm  of  the  splenius  mus- 
cle of  the  head  also  gives 
rise  to  an  abnormal  position 
of  the  head.  The  muscle 
turns  the  head  toward  the 
diseased  side,  while  the  face 
and  the  chin  are  approxi- 
mated to  the  shoulder.  The 
contracted  muscle  is  visible  beneath  the  anterior  border  of  the 
trapezius,  and  the  sternomastoid  appears  relaxed  upon  the  diseased 
side  and  stretched  upon  the  healthy  side  (Fig.  71). 

When  spasm  of  the  rhomhoid  is  present  the  scapula  becomes 
approximated  to  the  vertebral  column,  and  cannot  be  moved  freely 
outward.  Elevation  of  the  arm  above  the  horizontal  level  is 
attended  with  resistance.  The  contracted  muscle  is  visible  and 
palpable  in  the  interscapular  space. 

Spasm  of  the  elevator  of  the  scapula  is  attended  with  elevation 
of  the  scapula,  particularly  its  inner  upper  angle.  The  head  is 
retracted.  The  contracted  muscle  appears  in  the  clavicular  fossa 
at  the  side  of  the  anterior  border  of  the  trapezius. 


Fig.  71.— Position  of  the  head  in  the  presence  of 
spasm  of  the  right  splenius  muscle  of  the  head. 


SPASM  OF   THE   DIAPHRAGM. 

Clonic  spasm  of  the  diaphragm,  also  designated  hiccough,  is  the 
best-known  variety.  While  the  diaphragm  contracts  suddenly 
and  air  endeavors  to  enter  the  air-passages,  the  chink  of  the 


512  NERVOUS  SYSTEM 

glottis  closes  and  then  a  gurgling  sound  is  heard.  The  condition 
may  corae  to  an  end  with  a  few  contractions  of  the  diaphragm, 
but  in  some  cases  it  persists  for  days  and  weeks,  and  the  patient 
complains  of  pain  and  disagreeal)le  sensations  along  the  points  of 
attachment  of  the  diaphragm.  Children  are  predisposed  in  marked 
degree  to  clonic  spasm  of  the  diaphragm,  which  may  occur  after 
overloading  the  stomach  and  after  hearty  laughter.  The  same 
causes  may  give  rise  also  to  clonic  spasm  of  the  diaphragm  in 
adults.  At  times  the  disorder  occurs  in  association  with  dla~ 
phragmatic  pleurisy  or  peritonitis,  or  with  irritation  of  the  j^hrenio 
nerve  by  mediastinal  tumors.  Disease  of  the  brain  (meningitis, 
hemorrhage,  softening)  also  is  at  times  attended  with  spasm  of  the 
diaphragm.  Occasionally  this  occurs  in  cases  of  hysteria.  Reflex 
clonic  spasm  of  the  diaphragm  has  been  observed  in  connection 
with  diseases  of  the  stomach,  the  intestine,  the  kidneys,  the  liver, 
and  the  sexual  organs.  Further,  there  are  cases  ivithout  obvious 
etiologic  factors. 

In  treatment  efforts  should  be  directed  first  to  the  removal  of 
the  cause — causal  therapy.  Among  symptomatic  measures  expulsive 
efforts  with  closure  of  the  chink  of  the  glottis,  rapidly  successive 
swallowing  of  w-ater,  the  introduction  of  a  sound  into  the  esopha- 
gus, constriction  of  the  lower  portion  of  the  thorax  Avith  simulta- 
neous strong  flexion  of  the  head,  and  the  like,  have  been  recom- 
mended. Among  medicaments,  nervines  and  narcotics  particularly 
have  been  employed.  In  cases  of  hysteria  psychic  treatment  is 
indicated.  I  have  effected  cure  by  means  of  regular  and  slow 
counting. 

Tonic  spasm  of  the  diaphragm  has  been  observed  as  a  result  of 
exposure  to  cold  and  in  the  sequence  of  infectious  diseases  (par- 
ticularly rheumatism,  tetanus).  At  times  it  is  dependent  upon 
disease  of  the  brain  (epilepsy,  hysteria).  It  may  be  recognized 
from  the  want  of  movement  in  the  greatly  distended  lower  portion 
of  the  thorax  in  respiration,  while  the  upper  portion  is  engaged  in 
active  and  labored  breathing.  The  lower  border  of  the  heart  and 
of  the  lungs  is  unusally  low,  and  exhibits  no  movement  with  respi- 
ration. Respiratory  movement  of  the  lower  border  of  the  liver  is 
likewise  not  demonstrable.  The  epigastrium  bulges  forward.  If 
speedy  relief  be  not  afforded,  death  will  result  from  suffocation. 
A  subcutaneous  injection  of  morphin  should  be  given  or  chloro- 
form-narcosis be  induced  in  order  to  overcome  the  tonic  spasm  of 
the  diaphragm.  If  these  measures  do  not  succeed,  faradization  of 
the  phrenic  nerves  should  be  practised. 

SPASM  OF  THE  ABDOMINAL  MUSCLES. 

Spasm  of  the  abdominal  muscles  is  generally  of  central  origin. 
Clonic  spasm  of  the  abdominal   muscles  has   occasionally  been 


NEURALGIA  513 

observed  in  connection  with  hysteria ;  tonic  spasm — recognizable 
from  the  hardness,  tension,  and  contraction  of  the  abdominal  walls 
— occurs  in  connection  with  tetanus  and  meningitis. 

MUSCULAR  SPASM  IN  THE  UPPER  AND  THE 
LOWER  EXTREMITIES. 

The  muscles  of  the  arms  and  the  legs  are  but  rarely  involved 
in  tonic  or  clonic  spasm.  The  condition  when  present  can  be 
readily  recognized. 

CRAMPS. 

The  best-known  example  of  tonic,  painful  muscular  spasm  is 
cramp  in  the  calf  of  the  leg.  The  patient  complains  suddenly  of 
intense  pain  in  the  calf  of  one  leg  and  at  the  same  time  the  mus- 
cles in  this  situation  are  thickened  and  contracted  with  board-like 
hardness.  As  a  rule,  the  pain  ceases  in  the  course  of  a  few  seconds, 
although  a  sense  of  weakness  persists  for  some  time.  Occasion- 
ally extravasations  of  blood  beneath  the  skin  are  observed  in  the 
region  of  the  calf.  Nervous  and  anemic  individuals  are  greatly 
predisposed  to  the  disorder.  At  times  it  develops  in  the  sequence 
of  over-use  on  the  part  of  the  calf-muscles  in  standing,  walking, 
swimming,  turning,  dancing.  The  cramps  in  the  calves  that  are 
observed  in  cases  of  Asiatic  cholera  and  diabetes  mellitus  appear 
to  be  dependent  upon  toxic  influences.  Cramps  in  the  calves 
develop  not  rarely  in  persons  with  varicose  dilatation  of  the  veins 
of  the  leg.  The  cramp  can  be  overcome  by  vigorous  rubbing,  by 
alcoholic  frictions,  and  by  subcutaneous  injection  of  morphin.  Be- 
sides, attention  should  be  given  to  the  causative  conditions. 

NEURALGIA. 
PRELIMINARY    CONSIDERATIONS. 

Neuralgia — nerve-pain — is  characterized  by  its  distribution  in 
the  course  of  diseased  sensory  nerves.  Either  the  pain  occurs  in 
attacks  or  it  is  greatly  increased  paroxysmally.  The  number  and 
the  duration  of  the  attacks  of  pain  are  susceptible  of  wide  varia- 
tion. The  pain  is  described  by  the  patient  as  gnawing,  burning, 
and  crushing,  and  not  rarely  becomes  so  intense  that  even  strong 
men  are  made  to  groan  and  are  incapacitated  from  all  physical  and 
mental  occupation.  Not  rarely  rest  at  night  is  greatly  disturbed. 
The  pressure-points  of  Valleix  are  peculiar  to  many  varieties  of 
neuralgia.  It  has  been  found  that  certain  points  in  the  course 
of  the  diseased  nerve  are  particularly  sensitive  to  pressure.  The 
pressure-points  are  definite  for  the  individual  nerves,  being  gen- 
erally situated  at  places  where  the  nerve  is  superficial  and  rests 

33 


514  NERVOUS  SYSTEM 

upon  bone,  so  tliat  it  is  readily  accessiljle  to  the  compressing 
finger.  Cutaneous  sensibility  in  tlie  distribution  of  the  diseased 
nerve  is  frequently  altered.  At  the  beginning  there  is  frequently 
hyperesthesia,  which  is  subsequently  followed  hy  anesthesia.  At 
times  vasomotor,  secretory,  and  trophic  d'lsturbances are  present.  It 
may  also  happen  that  severe  pain  radiates  throughout  an  exten- 
sive cutaneous  area,  and  it  may  give  rise  to  clonic  or  tonic  muscular 
spasm. 

Anatomic  alterations  may  be  wanting  in  the  nerve  even 
though  the  neuralgia  have  lasted  for  years,  while  in  other  instances 
neuritic  changes  are  found ;  and  accordingly  a  distinction  can  be 
made  between  neurotic  and  neuritic  neuralgia.  Further,  the  dif- 
ferential diagnosis  generally  is  extremely  difficult  during  life,  and 
often  impossible. 

Among  the  causes  for  neuralgia  are  the  same  conditions  that 
have  been  named  as  causes  for  peripheral  paralysis,  and  accord- 
ingly refrigeratory  {rheumatic),  traumatic,  infectious,  and  toxic  neu- 
ralgia may  be  distinguished.  It  has  also  been  maintained  that 
reflex  neuralgia  occurs,  developing  in  the  sequence  of  antecedent 
disease  in  remote  organs,  particularly  in  the  female  generative 
organs.  Such  nerves  as  lie  superficially  and  pursue  a  long  course 
or  pass  through  narrow  bony  canals  are  readily  exposed  to  injury. 
The  sciatic  and  the  trigeminus  are,  therefore,  attacked  by  neu- 
ralgia with  particular  frequency.  Among  the  infectious  forms  of 
neuralgia  the  malarial  variety  is  especially  well  known,  and  this 
mav  be  the  sole  manifestation  of  malarial  infection,  and  is  charac- 
terized by  its  intermittent  occurrence.  It  is  remarkable  that 
typically  recurring  neuralgia,  so-called  masked  intermittent,  may 
occur  in  regions  free  from  malaria  and  attack  persons  A\ho  have 
never  lived  in  malarial  regions,  so  that  doubt  as  to  the  malarial 
nature  of  some  cases  of  intermittent  neuralgia  appears  justified, 
doubt  that  may  perhaps  be  removed  by  examination  of  the  blood 
for  malarial  plasmodia.  In  addition  to  malaria,  syphilis  is  yet  a 
common  cause  for  neuralgia.  Among  the  toxic  varieties  of  neu- 
ralgia may  be  included  the  uremic,  the  gouty,  and  the  diabetic, 
and  Avhich  more  appropriately  may  be  designated  autotoxic. 
Experience  has  shown  that  members  of  nervous  families  and  pale, 
nervous,  debilitated  individuals  are  attacked  by  neuralgia  with 
particular  frequency  and  readiness.  Women  are  more  greatly 
predisposed  to  neuralgia  than  men. 

The  curability  of  neuralgia,  depends  essentially  upon  its  causes. 
At  times  it  persists  throughout  life,  and  embitters  the  existence 
of  the  patient  to  such  a  degree  as  to  induce  suicide. 

The  treatment  of  neuralgia  should  be,  in  the  first  place, 
causal.  Should  exposure  to  cold  have  been  operative,  resort  may 
be  had  to  diaphoretics,  hot  fomentations,  applications  of  cotton 
batting,  and  the  internal  administration  of  salicylic  acid  or  sodium 


NEURALGIA  515 

salicylate  (1.0 — 15  grains — every  two  hours),  of  antipyrin  (1.0 — 
15  grains — thrice  daily),  or  phenacetin  (1.0 — 15  grains — thrice 
daily).  AVhen  syphilis  is  the  etiologic  factor  inunctions  of  mer- 
curial ointment  (5.0 — 75  grains — daily),  and  internally  potassium 
iodid  (5.0:200 — 75  grains  :  6^  fluidounces;  15  c.c. — one  table- 
spoonful — thrice  daily)  may  be  prescribed.  Malarial  influences  will 
indicate  the  employment  of  quinin  hydrochlorate  (from  1.0  to  5.0 
— from  15  to  75  grains — to  be  given  three  hours  in  advance  of 
the  expected  paroxysm).  At  times  surgical  intervention  will  be 
required  for  the  removal  of  the  cause  of  neuralgia,  as,  for  instance, 
in  the  removal  of  a  tumor  exerting  pressure  upon  a  nerve,  and 
the  like.  Among  symptomatic  measures  subcutaneous  injection  of 
morpliiii  is  the  most  reliable,  but  in  cases  of  obstinate  neuralgia 
there  Avill  be  risk  that  the  patient  will  demand  progressively 
increasing  doses,  and  become  a  morphin-habitue,  particularly  if 
he  be  entrusted  with  a  syringe  and  a  solution  of  morphiu : 

R  Morphin  hydrochlorate,  0.3    (4J  grains) ; 

Glycerin, 

Distilled  water,  each,  5.0    (75  minims). — M. 

Dose :  From  0.25  to  0.5  (4  to  8  minims)  subcutaneously. 

Even  when  malarial  infection  is  not  suspected  quinin  hydro- 
chlorate  (from  1.0  to  5.0 — from  15  grains  to  75  grains — in  tablet) 
is  a  useful  remedy.  In  addition,  nervines  and  narcotics  of  all 
kinds  have  been  employed.  It  will  suffice  to  mention  a  few  ex- 
amples from  which  success  may  most  likely  be  expected : 

R  Bitter-almond  water, 

Solution  of  potassium  arseuite,      each,  5.0  (75  minims). — M. 
Dose :  10  drops  thrice  daily  after  eating. 

R  Atropin  sulphate,  0.01  (i  grain) ; 

Glycerin, 

Distilled  water,  each,  5.0  (75  minims). — M. 

Dose :  0.25  (4  minims)  subcutaneously. 

R  Solution  of  cocain  hydrochlorate,  0.5  :  10.0  (7i  grains  : 

2^  fluidrams). 
Dose:  0.5  (8  minims)  subcutaneously. 

R  Exalgin,  •  0.3  (4i  grains) ; 

Sugar,  0.5  (7J       "     ).— M. 

Make  10  such  powders. 
Dose  :  1  powder  thrice  daily. 

R  Tincture  of  gelsemium,  20.0  (5  fluidrams). 

Dose :  10  drops  thrice  daily. 

R  Butyl  chloral  hydrate,  5.0  (75  grains) ; 

Glycerin,  20.0  (5  fluidrams) ; 

Distilled  water,  130.0  (4  fluidounces).— M. 

Dose  :  15  c.c.  (1  tablespoonful)  every  five  or  ten  minutes  until  half 
the  prescription  is  used. 

Alcoholic  frictions  and  narcotic  and  irritating  ointments  have 
also  been  considerablv  used.     It  is  a  matter  of  indiifereuce  with 


516  NERVOUS  SYSTEM 

regard  to  the  results  whether  spirit  of  mustard,  spirit  of  camphor, 
spirit  of  formic  acid,  or  compound  spirit  of  angelica  be  employed. 
Chloroform-liniment  also  may  be  used  : 

R  Chloroforii),  10.0  (2^  fluidrams) ; 

Ammoniated  liniment,  40.0  (10         "        ). — M. 

Apply  with  friction. 

The  following  examples  of  narcotic  and  irritating  ointments 
may  be  given  : 

R  Morphin  hydrochlorate,  0.1  (1^  grains); 

Wool-fat, 

Lard,  each,  5.0  (75       "     ).— M. 

For  inunction. 

R  Extract  of  belladonna,  2.0  (30  grains)  j 

Wool- fat. 

Lard  each,  5.0  (75      "     ).— M. 

For  external  application. 

R  Veratrin,  0,3  (4^  grains) ; 

Wool-fat, 

Lard,  each,  25.0  (6  drams).— M. 

For  inunction. 

Leeches,  wet  cups,  and  applications  of  ice  to  the  nerve  and  hot 
fomentations  have  also  been  employed  considerably.  Some  pa- 
tients are  greatly  relieved  by  the  employment  of  the  galvanic  cur- 
rent. The  current  should  not  be  too  strong  and  the  anode  (+  pole, 
copper-pole)  should  be  applied  to  the  affected  nerve.  The  ap])li- 
cation  should  be  repeated  daily,  but  should  not  be  continued  longer 
than  from  three  to  five  minutes.  Treatment  with  the  faradic  brush 
may  also  yield  good  results.  In  obstinate  and  distressing  cases 
resort  has  been  had  to  surgical  measures,  and  nerve-stretching, 
nerve-section  (neurotomy),  nerve-resection  (neurectomy),  and  re- 
cently also  the  extraction  of  exposed  nerves  by  means  of  forceps 
have  been  practised.  Unfortunately,  all  of  these  efforts  are 
attended  either  with  no  result  or  too  frequently  with  only  a  tran- 
sient result.  Any  effect  will  be  wanting  if  the  operation  fails  to 
reach  the  seat  of  the  neuralgia,  and  this  may  happen  all  the  more 
readily  as  no  remedy  is  known  that  is  capable  of  determining  with 
certainty  the  seat  of  neuralgia.  Neuralgia  cured  by  operation  re- 
curs readily  after  the  divided  or  exsected  nerve  has  united  or 
reformed,  and  this  may  happen  even  Avhen  remarkably  long  por- 
tions of  the  nerve  have  been  removed.  Great  care  should  there- 
fore be  exercised  in  promising  a  successful  result. 

TRIGEMINAL  NEURALGIA. 

histiology. — Trigeminal  neuralgia  is  one  of  the  commonest 
varieties  of  neuralgia,  as  the  branches  of  the  trigeminal  nerve  pass 
through  several  bony  canals  and  in  part  lie  superficially,  so  that 


TRIGEMINAL  NEURALGIA  517 

they  may  be  readily  aifected  by  injurious  influences.  Refrigera- 
tory trigeminal  neuralgia  occurs  with  certainty,  and  it  may  develop, 
among  other  conditions,  when  individual  branches  are  exposed  to 
a  draft  of  cold  air  or  to  rain.  Among  the  forms  of  infectious 
neuralgia  the  best  known  is  that  of  malarial  origin.  Trigeminal 
neuralgia,  however,  occurs  not  at  all  rarely  in  connection  with 
typhoid  fever,  syphilis,  and  influenza.  Toxic  trigeminal  neuralgia 
has  been  observed  as  a  result  of  the  action  of  lead,  mercury,  and 
iodin,  and  in  cases  of  gout  and  of  diabetes.  Traumatic  trigeminal 
neuralgia  occurs  frequently.  Among  the  causes,  contusions  and 
stab-wounds  of  the  nerve,  periostitis  of  the  cranial  bones,  com- 
pression by  a  neoplasm,  the  extension  of  neoplastic  proliferation 
into  the  trunk  of  the  nerve,  inflammatory  processes  in  the  teeth 
or  the  jaw,  in  the  nose  or  in  the  frontal  sinuses,  and  in  the  eye  and 
the  ear.  At  times  trigeminal  neuralgia  is  dependent  upon  disease 
at  the  base  of  the  skull  (syphilitic  inflammation  and  thickening  of 
the  meninges,  tumors,  aneurysms  of  the  cerebral  arteries).  Chil- 
dren generally  are  exempt  from  trigeminal  neuralgia,  excepting 
alveolar  neuralgia  (toothache).  Women  are  attacked  more  fre- 
quently than  men,  and  pale  and  nervous  persons  in  greater  num- 
ber than  the  robust. 

Symptoms  and  Diagnosis. — Trigeminal  neuralgia  is,  as  a 
rule,  unilateral.  Naturally,  after  the  lapse  of  a  certain  time  it  may 
gradually  extend  to  the  opposite  trigeminal  nerve,  while  the  nerve 
first  involved  becomes  free  from  pain.  Only  rarely  are  all  three 
branches  of  the  trigeminal  nerve  simultaneously  attacked  by  neur- 
algia, and  such  a  circumstance  must  be  indicative  of  a  basal  origin, 
as  the  branches  lie  close  together  in  this  situation.  Most  commonly 
only  a  few  branches  of  the  trigeminal  nerve  are  affected  by  neur- 
algia. Of  all  of  the  branches  of  the  trigeminal  nerve  the  supra- 
orbital is  most  commonly  attacked. 

At  times  the  neuralgia  is  preceded  by  certain  paresthesias  (a 
sense  of  crawling  or  of  coldness  or  of  stiflness)  as  prodromes. 
The  pain  may  possess  a  burning,  boring,  or  crushing  character, 
and  at  times  attains  an  unendurable  intensity.  The  duration  of 
an  attack  of  pain  and  the  frequency  of  its  recurrence  vary  ex- 
tremely. The  individual  attack  of  pain  sets  in  at  times  without 
recognizable  cause,  but  at  other  times  it  is  excited  by  emotional 
disturbances,  a  draft  of  air,  glaring  light,  eating,  drinking,  or  the 
like.  In  the  course  of  the  aifected  nerve  Valleix's  pressure-points 
can  generally  be  demonstrated.  Cutaneous  sensibility  is  at  first 
generally  heightened,  but  subsequently  becomes  diminished  or,  less 
commonly,  lost.  Vasomotor  disturbances  are  at  first  indicated  by 
arterial  spasm  and  pallor  of  the  skin,  and  soon  vascular  dilata- 
tion occurs,  with  corresponding  redness  and  warmth  of  the  skin. 
Among  secretory  disturbances  increased  secretion  of  tears,  of  nasal 
mucus  (at  times  bloody),  of  saliva,  and  of  perspiration  has  been 


518 


NERVOUS  SYSTEM 


observed.  Trophic  disturbances  are  less  common,  and  they  may 
consist  in  increase  or  diminution  in  the  fatty  layer  of  the  skin, 
coarseness,  graying,  and  loss  of  the  hair,  eruptions  of  herpes,  iritis, 
glaucoma,  or  neuroparalytic  ophthalmia.  Severe  attacks  of  pain 
are  at  times  attended  with  clonic  muscular  spasm  in  the  face  and  at 
times  also  in  the  extremities.  When  the  causative  conditions  are 
incurable  the  disorder  may  persist  for  many  years,  and  even 
throuo-hout  the  ^vhole  of  life.  The  fear  of  an  attack  of  neuralgia 
in  eating,  sleeplessness  at  night,  and  seclusion  result  in  physical 
and  moral  depressi(m,  and  may  lead  to  suicide.  For  those  familiar 
with  the  anatomic  distribution  of  the  trigeminal  nerve  there  is  no 


Fig.  72.— Distribution  of  the  trigeminal  nerve  upon  the  face. 

difficulty  in  determining  with  certainty  the  branch  of  the  nerve 
that  is  tiie  seat  of  neuralgia.  For  ready  recognition  reference  may 
be  made  to  Fig.  72,  and  we  shall  confine  ourselves  to  the  following 
diagnostic  points  : 

In  cases  of  sujjraorbital  neuralgia  the  pain  radiates  from  the 
supraorbital  margin  to  the  frontal  region,  toward  the  root  of  the 
nose,  and  into  the  upper  eyelid.  The  most  constant  pressure-point 
is  situated  just  below  the  supraorbital  foramen  in  the  roof  of  the 
orbit. 

Infraorbital  neuralgia  is  attended  with  pain  radiating  from  the 
infraorbital  margin  along  the  cheek  to  the  upper  lip  and  the  lateral 


CERVICO-OCCIPITAL  NEURALGIA  519 

aspect  of  the  nose.  The  distinctive  pressure-point  is  at  the  infra- 
orbital foramen. 

Lingual  neuralgia  or  glossalgia  is  attended  with  severe  pain  in 
one-half  of  the  tongue,  and  often  with  coating  of  part  of  the 
tongue,  together  with  thickening  of  this  half  of  the  tongue  and 
increased  secretion  of  saliva. 

The  diagnosis  should  never  be  considered  complete  with  the 
localization  of  the  neuralgia,  but  in  every  instance  an  effort  should 
be  made  to  determine  the  causative  factors. 

Prognosis. — The  prognosis  depends  upon  the  curability  of 
the  causative  factors. 

Treatment. — The  treatment  is  the  same  as  that  described  on 
pp.  514-516.  In  obstinate  cases  resort  has  been  had  to  com- 
pression and  even  to  ligation  of  the  common  carotid  artery,  but 
without  certainty  as  to  the  result. 

CERVICO-OCaPITAL  NEURALGIA* 

Ktiology. — From  the  cervical  plexus,  formed  from  the  highest 
four  cervical  nerves,  five  sensory  nerves  are  given  ofF:  the  greater 
and  the  lesser  occipital,  the  great  auricular,  the  inferior  subcuta- 
neous of  the  neck,  and  the  supraclavicular,  of  which  any  one  may 
be  attacked  alone  by  neuralgia,  or  in  rare  instances  all  may  suffer 
together.  Most  commonly  neuralgia  of  the  greater  occipital  is 
present,  and  the  condition  is  for  brevity's  sake  designated  occipital 
neuralgia.  The  causes  for  the  varieties  of  neuralgia  under  con- 
sideration have  already  been  mentioned  several  times.  Occipital 
neuralgia  is  observed  particularly  after  injuries  to  the  scalp,  and 
further  in  association  with  syphilis  and  uremia.  At  times  cervico- 
occipital  neuralgia  is  dependent  upon  disease  of  the  cervical  verte- 
brae (tuberculosis,  tumors)  or  upon  disease  of  the  spinal  membranes 
or  of  the  cervical  cord  itself. 

Symptoms  and  Diagnosis. — OccijMal  neuralgia  is  attended 
with  pain  radiating  from  the  occiput  to  the  parietal  bone.  A 
pressure-point  is  situated  at  the  point  of  exit  of  the  occipital  nerve 
between  the  mastoid  process  and  the  atlas.  Occasionally  there 
appear  at  the  time  of  the  attack  of  pain  redness  of  the  face,  secre- 
tion of  tears,  contraction  of  the  pupils,  and  vomiting.  The  hair  may 
fall  out  and  nodules  may  form  beneath  the  scalp.  The  duration 
of  the  disorder  depends  upon  the  nature  of  the  causative  factors. 

Neuralgia  of  the  lesser  occipital  nerve  is  attended  with  pain  in 
the  lateral  aspect  of  the  occiput  and  extending  to  the  ear.  A 
pressure-point  is  situated  at  the  point  of  exit  of  the  nerve  just 
behind  the  mastoid  process.  In  cases  of  neuralgia  of  the  great 
auricular  nerve  the  patients  complain  of  pain  above  the  mastoid 
•process,  upon  the  posterior  aspect  of  the  auricle,  and  in  the  parotid 
gland,  while  neuralgia  of  the  inferior  subcutaneous  nerve  of  the 


520  NERVOUS  SYSTEM 

neck  is  attended  with  pain  in  the  anterior,  inferior,  and  median 
portions  of  the  neck,  and  neuralc/ia  of  the  supraclavicular  nerve 
with  pains  in  the  region  of  the  acromion,  the  shoulder,  and  tlie 
upper  portion  of  the  thorax. 

PHRENIC  NEURALGIA* 

The  designation  plirenic  neuralgia  has  been  given  to  pain  occur- 
ring paroxysmally  in  the  course  of  the  phrenic  nerve  and  at  the 
points  of  attachment  of  the  diaphragm,  and  often  giving  rise  to 
marked  difficulty  in  breathing.  The  occurrence  of  such  a  variety 
of  neuralgia  has  not  without  reason  been  doubted.  Among  the 
causative  factors  that  have  been  named  are  disease  of  the  heart, 
aneurysm  of  the  aorta,  disorders  of  the  liver,  the  kidneys,  the  in- 
testine and  the  spleen,  pleurisy,  pericarditis,  and  peritonitis. 

CERVICOBRACHIAL  NEURALGIA. 

Neuralgia  involving  the  sensory  nerves  of  the  brachial  plexus 
(from  the  fourth  to  the  eighth  cervical  and  the  first  dorsal  nerve) 
occurs  frequently.  Generally  it  is  of  traumatic  origin  (contusion, 
compression,  incised,  punctured,  and  gunshot  wounds,  and  the 
likej.  Often  several  nerve-tracts  are  involved  at  the  same  time. 
At  times  vasomotor  and  also  trophic  disturbances  occur  (herpes, 
abnormal  growth  of  hair,  glossy  fingers).  At  times  muscular 
weakness  and  atrophy  are  superadded  to  neuralgia. 

DORSO-INTERCOSTAL  NEURALGIA. 

Ktiology. — The  twelve  dorsal  nerves,  after  leaving  the  verte- 
bral canal  through  the  intervertebral  foramina,  divide  into  poste- 
rior and  anterior  branches.  The  posterior  nerve-roots  or  dorsal 
nerves  are  distrii)uted  upon  the  skin  of  the  back  down  to  the 
sacrum,  and  are  rarely  the  seat  of  neuralgia.  The  anterior  nerve- 
roots  or  intercostal  nerves,  however,  are  attacked  all  the  more  fre- 
quently, and  the  causative  factors,  as  with  other  neuralgias,  are 
principally  exposure  to  cold,  injury,  infection,  and  intoxication. 
Among  the  injuries  it  should  be  noted  that  some  cases  are  depen- 
dent upon  disease  of  the  vertel)ral  column  (tuberculosis,  carci- 
noma), and  that  intercostal  neuralgia  may  at  times  be  secondary 
to  pleurisy,  possibly  because  intercostal  nerves  become  compressed 
and  irritated  by  connective-tissue  cicatrices.  Often  intercostal 
neuralgia  precedes  or  is  followed  by  herpes  zoster.  Malaria  has 
also  been  ol^served  to  be  a  causative  factor. 

Symptoms  and  Diag^nosis. — Intercostal  neuralgia  is  gen- 
erally unilateral,  most  commonly  left-sided,  and,  as  a  rule,  attacks 
several    contisfuous    intercostal    nerves  at   the   same   time.     The 


CRURAL  NEURALGIA  521 

nerves  between  the  fifth  and  the  ninth  are  involved  with  especial 
frequency.  The  pain  is  characterized  by  its  radiation  about  one- 
half  of  the  chest.  Pressure-points  are  present  close  to  the  vertebral 
column,  in  the  axillary  region,  and  close  to  the  margin  of  the 
sternum,  and  are  designated  as  vertebral,  lateral,  and  sternal 
points  respectively.  Hyperesthesia  and  subsequently  anesthesia 
of  the  skin  are  observed  frequently.  Among  trophic  disturbances 
herpes  occurs  not  rarely.  The  patient  often  complains  of  dis- 
turbed sleep  and  of  difficulty  in  breathing,  laughing,  sneezing, 
and  coughing,  because  the  pain  is  excited  or  intensified  by  these 
acts.  Accurate  limitation  of  the  pain  in  the  course  of  the  inter- 
costal spaces  and  the  absence  of  pleuritic  friction-sounds  and  of 
alterations  in  the  ribs  readily  distinguish  intercostal  neuralgia  from 
muscular  rheumatism,  dry  pleurisy,  and  inflammation  of  the  ribs. 

Neuralgia  of  the  mammary  gland  or  mastodynia  also  is  a  variety  of  inter- 
costal neuralgia,  because  in  addition  to  tbe supraclavicular  nerves  the  mam- 
mary gland  receives  branches  also  from  the  second  to  the  sixth  intercostal 
nerve.  The  disorder  is  most  common  in  women,  particularly  hysterical 
and  anemic  women,  and  it  develops  at  times  in  the  sequence  of  injury  to 
the  gland  or  of  unduly  protracted  lactation.  At  times  small  indurations — 
so-called  neuralgic  nodes — are  present  in  the  painful  gland.  The  disorder 
is  attended  with  attacks  of  unbearable  pain  in  one  breast  or  in  both.  At 
times  a  colostrum-like  fluid  is  secreted  during  an  attack  of  pain.  The 
attack  occasionally  persists  for  more  than  an  hour.  The  obstinacy  and  the 
severity  of  the  pain  have  induced  some  patients  to  have  the  gland  ampu- 
tated. 

LUMBO-ABDOMINAL  NEURALGIA. 

Lumbo-abdominal  neuralgia  includes  involvement  of  the  ilio- 
hypogastric, ilio-inguinal,  lumbo-inguinal,  and  external  spermatic 
nerves,  which  originate  from  the  four  upper  lumbar  nerves.  The 
painful  area  extends  over  the  lumbar  and  gluteal  regions,  the 
scrotum  or  the  labia  majora,  and  the  anterior  aspect  of  the  thigh. 
A  pressure-point  is  frequently  found  at  the  middle  of  the  crest  of 
the  ilium.  At  the  time  of  the  attack  of  pain  there  may  be  pria- 
pism, discharge  of  seminal  fluid,  or  leukorrhea.  In  addition  to 
exposure  to  cold,  disease  of  the  vertebral  column,  exudates  and 
tumors  in  the  pelvis,  and  displacements  of  the  uterus  particularly 
give  rise  to  lumbo-abdominal  neuralgia. 

CRURAL  NEURALGIA. 

Crural  neuralgia  is  uncommon,  and  when  it  occurs  is  generally 
of  traumatic  origin.  Disease  of  the  vertebral  column,  exudates 
and  tumors  in  the  pelvis,  aneurysms  of  the  femoral  artery,  and 
crural  hernias  have  been  named  as  causes  of  crural  neuralgia. 
The  pains  are  distributed  especially  upon  the  anterior  and  inter- 
nal aspect  of  the  thigh,  and,  in  the  course  of  the  greater  saphenous 
nerve,  along  the  inner  aspect  of  the  leg  and  the  inner  border  of 


522  NERVOUS  SYSTEM 

the  foot  to  tlic  groat  toe.  Pressure-points  may  be  present  as  fol- 
lows :  A  crural  point,  just  below  Poupart's  ligament,  correspond- 
ing to  the  point  of  exit  of  the  crural  nerve ;  a  knee-point  on  the 
inner  aspect  of  the  knee-joint;  a  plantar  point,  in  front  of  the 
internal  malleolus ;  and  a  toe-point,  at  the  base  of  the  great  toe. 

OBTURATOR   NEURALGIA. 

Obturator  neuralgia  may  set  in  suddenly  in  connection  with 
strangulated  obturator  hernia,  and  is  therefore  of  diagnostic  im- 
portance. The  pain  extends  along  the  inner  aspect  of  the  thigh 
to  the  knee.  Generally  the  adductors  of  the  thigh  are  paralyzed 
at  the  same  time. 

NEURALGIA  OF  THE  EXTERNAL  CUTANEOUS 
NERVES  OF  THE  THIGH. 

The  pain  extends  upon  the  outer  aspect  of  the  thigh  to  the 
knee.  I  have  observed  this  variety  of  neuralgia  frequently  in 
individuals  who  have  supported  one  knee  upon  the  other  for  long 
periods  of  time. 

SCIATIC  NEURALGIA. 

Ktiology. — Among  all  of  the  varieties  of  neuralgia  sciatic 
neuralgia,  also  designated  sciatica,  occurs  most  commonly.  The 
nerve  may  readily  suffer  from  exposure  to  cold  and  traumatism 
on  account  of  its  superficial  position  and  its  long  course,  but  infec- 
tious and  toxic  neuralgia  of  the  sciatic  nerve  is  also  known. 
Working  in  the  damp  (as  in  digging  canals,  Avorking  in  the  woods 
or  in  fortresses,  sleeping  in  damp  rooms  and  in  the  open  air,  and 
the  like)  is  often  followed  by  sciatica.  Among  the  traumatic 
causative  factors  may  be  mentioned  a  fall,  a  blow,  or  contusion 
involving  the  gluteal  region,  heavy  lifting  and  long  standing, 
fractures  and  luxations  of  the  thigh,  neoplasms  and  exudates  in 
the  vicinity  of  the  sciatic  nerve,  displacements  and  neoplasms  of 
the  nterus  and  the  ovaries,  parametric  and  perimetric  exudates, 
pregnancv,  fecal  accumulation  in  the  rectum,  tumors  of  the  pelvic 
bones,  luxations,  fractures,  and  tumors  of  the  vertebrae,  hemor- 
rhage, inflammation,  and  tumors  of  the  spinal  membranes,  and 
the  like.  Among  the  varieties  of  toxic  sciatic  neuralgia  those 
occurring  in  the  course  of  diabetes  mclHtus  mnst  be  included,  and 
Avhich  at  times  are  bilateral  and  exceedingly  obstinate.  Bilateral 
and  usually  resistant  sciatica  is  observed  not  rarely  in  cases  of 
tabes  dorsalis.  The  disease  generally  attacks  adults,  and  men 
more  commonly  than  women. 

Anatomic  Alterations. — But  few  reports  have  been  made 


SCIATIC  NEURALGIA  523 

as  to  the  anatomic  alterations  attending  sciatica.  In  some  cases 
the  nerve  is  said  to  have  been  uninjured — neurotic  sciatica — while 
in  others  it  has  been  inflamed — neuritic  sciatica.  At  times  car- 
cinomatous masses  have  penetrated  the  nerve  from  the  neighbor- 
hood, and  have  developed  within  it.  In  a  case  of  sciatica  follow- 
ing purpura  I  found  extensive  hemorrhage  into  the  nerve.  At 
times  collections  of  serous  fluid  have  been  reported  as  present  in 
the  nerve-sheath. 

Symptoms  and  Diagnosis. — Sciatica  is  frequently  recog- 
nized without  difficulty,  because  the  patient  Avill  indicate  with  his 
finger  accurately  the  course  of  the  sciatic  nerve  as  the  painful  area. 
The  pain  extends  from  the  point  of  exit  of  the  sciatic  nerve  in  the 
region  of  the  hip  down  to  the  toes.  Naturally,  partial  sciatica 
occurs  at  times,  so  that  perhaps  the  pain  extends  only  along  the 
posterior  aspect  of  the  thigh,  or  along  the  calf  of  the  leg,  or  is 
present  only  on  the  plantar  aspect  of  the  foot.  Accordingly  as 
the  pain  radiates  from  above  downward  or  in  the  reverse  direction 
a  distinction  has  been  made  between  descending  and  ascending 
sciatica,  although  this  is  not  of  much  practical  value,  as  many 
patients  state  that  the  pain  occurs  simultaneously  throughout  the 
whole  course  of  the  sciatic  nerve.  The  number,  duration,  and 
severity  of  the  attacks  exhibit  great  variations.  Pressure-points 
are  present  at  the  side  of  the  sacrum,  at  the  level  of  the  posterior 
superior  iliac  spine,  at  the  lower  border  of  the  gluteus  correspond- 
ing to  the  point  of  exit  of  the  sciatic  nerve  from  the  sciatic  notch, 
at  a  point  just  behind  the  greater  trochanter,  at  the  middle  of  the 
posterior  aspect  of  the  thigh  (bifurcation  of  the  posterior  cuta- 
neous nerve  of  the  thigh),  in  the  popliteal  space  (tibial  nerve),  at 
a  point  just  below  the  head  of  the  fibula  (peroneal  nerve),  and  at 
a  point  each  behind  the  external  and  the  internal  malleolus. 
Vasomotor  and  trophic  disturbances  are  not  common.  Standing 
and  walking  cause  increase  in  the  severity  of  the  pain,  and  for 
this  reason  the  patient  shields  the  neuralgic  extremity.  It  is, 
therefore,  not  surprising  that  muscular  atrophy  from  disuse  slowly 
takes  place.  Rapid  degenerative  muscular  atrophy  occurs  when 
the  sciatica  is  of  neuritic  origin.  Under  such  conditions  cutaneous 
anesthesia  and  impairment,  and  even  abolition,  of  the  knee-jerk  may 
readily  be  present. 

On  standing,  it  is  not  rarely  observed  that  the  spinal  column  undergoes 
lateral  curvature — scoliotic  sciatica.  Generally  the  convexity  of  the  curva- 
ture is  directed  toward  the  diseased  side  and  less  commonly  toward  the 
healthy  side.  An  uncommon  complication  is  the  presence  of  sugar  in  the 
urine. 

The  duration  of  sciatica  varies  between  a  few  weeks  and  many 
years.  Some  patients  are  never  relieved  of  their  disorder.  Also, 
relapses  occur  readily  and  repeatedly.  The  danger  of  confound- 
ing sciatica  and  coxitis  is  particularly  great.     In  the  diagnosis  of 


524  NERVOUS  SYSTEM 

the  latter  tlie  distinetive  position  of  the  lower  extremity  (flexion 
of  tiic  thigh  and  the  leg  with  rotation  outward)  and  the  circum- 
stance that  kicking  and  rotatory  movements  of  the  thigh  are  pain- 
ful in  the  presence  of  sciatica  and  usually  are  greatly  interfered 
with,  while  they  are  free  and  unattended  with  pain  in  the  presence 
of  sciatica,  must  be  taken  into  consideration. 

Prognosis. — Sciatica  is  an  obstinate  and  even  an  incurable 
disorder,  but  it  is  not  attended  with  any  immediate  danger  to  life. 
Naturally,  the  patients  may  become  greatly  debilitated  in  conse- 
quence of  pain  and  persistent  insomnia,  and  also  nervous. 

Treatment. — In  treatment  an  endeavor  should  first  be  made 
to  meet  the  causal  indications  in  the  usual  manner  according  to 
the  suggestions  already  laid  down.  Under  all  circumstances  rest 
in  bed  and  an  equable  temperature  are  particularly  serviceable 
measures.  No  specific  remedy  for  sciatica  is  known,  so  that  the  treat- 
ment must  be  conducted  upon  the  lines  indicated  on  pp.  514-516. 
In  chronic  cases  courses  of  treatment  with  baths  have  been  re- 
sorted to,  and  indifferent  thermal,  saline,  or  sulphurous  baths  par- 
ticularly have  been  recommended.  At  times  I  have  secured  suc- 
cessful results  by  means  of  bloodless  stretching  of  the  sciatic  nerve, 
the  extended  extremity  being  flexed  as  strongly  as  possible  at  the 
hip-joint  and  moved  toward  the  abdomen. 

SPERMATIC  NEURALGIA. 

Spermatic  neuralgia  is  attended  with  pain  in  the  testicle  and 
the  epididymis,  radiating  in  the  course  of  the  spermatic  cord  to 
the  lumbar  region.  At  times  swelling  of  the  testicle  also  occurs. 
Among  the  etiologic  factors  may  be  mentioned  onanism,  other 
sexual  excesses,  antecedent  gonorrheal  epididymitis,  injuries, 
anemia,  and  neurasthenia.  Further,  excessive  sexual  continence 
has  been  thought  to  cause  the  disorder.  The  testicle  should  be 
supported  with  a  suspensory  bandage,  narcotic  ointments  be  applied 
by  inunction,  in  the  presence  of  severe  pain  an  injection  of  mor- 
phin  be  made,  electricity  be  employed,  and  the  general  condition 
be  treated.  In  obstinate  cases  the  painful  testicle  has  been  re- 
moved. 

Neuralgia  of  the  glans  and  the  penis,  the  scrotum,  the  labia  viajora,  the 
urethra,  ?in(!i  the,  perinenm  ha?,  also  been  described.  Among  the  causative 
factors  are  exposure  to  cold,  injuries,  and  sexual  excesses. 

COCCYGODYNIA. 

Neuralgia  of  the  coccyx — coccygodynia — is  attended  with  severe 
pain  in  the  coccygeal  region,  which  becomes  increased  to  an  intol- 
erable degree  on  sitting,  walking,  and  expulsive  effort.  The 
disorder  generally  occurs  in  women,  and  is  attributed  to  injuries. 


ANESTHESIA  525 

difficulty  in  labor,  or  exposure  to  cold.  Further,  in  many  instances 
the  condition  appears  to  be  really  not  a  neuralgia,  but  an  inflam- 
matory condition  of  the  coccyx.  In  obstinate  and  painful  cases 
the  coccyx  has  been  removed. 

ARTICULAR  NEURALGIA. 

Articular  neuralgia  occurs  especially  in  pallid,  nervous,  or  hys- 
terical individuals.  It  may  develop  spontaneously  or  after  ex- 
posure to  cold  or  as  a  result  of  injury.  Most  commonly  the  knee- 
joint  or  the  hip-joint  is  the  seat  of  the  disorder.  In  contradis- 
tinction from  anatomically  demonstrable  arthritis,  the  patient  usu- 
ally keeps  the  extremity  extended  and  avoids  all  movement.  After 
the  disorder  has  persisted  for  some  time  muscular  atrophy  from 
disuse  may  result.  It  is  often  exceedingly  difficult  to  distinguish 
articular  neuralgia  from  arthritis. 

The  treatment  should  be  directed  against  the  general  condition. 
In  addition,  the  patient  should  be  encouraged  to  use  the  joint. 
At  times  it  is  necessary  to  insist  upon  such  use  of  the  joint. 
Occasionally  recovery  takes  place  abruptly. 

ANESTHESIA. 

Sensory  disturbances  of  the  skin  and  the  mucous  membranes 
are  attended  with  either  total  or  only  partial  loss  of  sensibility, 
and  accordingly  a  distinction  is  made  between  anesthesia  and  hy- 
peresthesia. Accordingly  as  all  varieties  of  sensation  or  but  a 
single  variety  is  lost  the  result  will  be  total,  or  payiial  anesthesia, 
although  the  condition  can  be  recognized  only  from  a  careful  study 
of  all  varieties  of  sensation. 

In  what  follows  cutaneous  anesthesia  alone  will  be  considered,  although 
naturally  conditions  of  anesthesia  and  hyperesthesia  may  occur  wherever 
there  are  sensory  nerves,  as,  for  instance,  in  muscles,  joints,  fascia,  tendons, 
periosteum,  and  internal  viscera. 

Cutaneous  sensibility  includes  both  the  sense  of  touch  and  com- 
mon sensation.  Each  of  these  principal  divisions  can  be  sub- 
divided into  several  subgroups,  and  accordingly  the  following 
scheme  of  examination  may  be  adopted : 

Tactile  Sensibility : 

Contact-sense ; 
Pressure-sense ; 
Localization-sense ; 
Time-sense ; 
Temperature-sense. 


526 


XER  VO US  SYSTEM 


Common  Sensibility : 
Pain-seiise  ; 
Electric  sensibility ; 
The  sense  of  tickling. 

In  investigating  cutaneous  sensibility  it  should  be  a  rule  to  employ  the 
simplest  methods  of  examination.  In  order  not  to  distract  the  attention  of 
the  patient,  it  is  well  for  him  to  keep  his  eyes  closed  during  the  examina- 
tion, and  if  possible  to  assume  a  comfortable  recumbent  posture.  Contact- 
sensibility  is  tested  by  touching  or  stroking  the  skin  with  a  blunt  body  (the 
finger,  a  hair-brush,  a  bit  of  wood,  a  swab  of  cotton,  a  roll  of  paper).  For 
purposes  of  comparison,  symmetric  portions  of  the  skin  or  in  the  presence 
of  para-anesthesia  higher  or  lower  portions  should  be  tested  successively. 
The  test-agent  should  be  neither  too  warm  nor  too  cold,  as  the  patient 
might  confound  the  thermal  sensation  with  that  of  contact.  The  simplest 
mode  of  testing  the  pressure-sense  consists  in  making  a  varying  degree  of 
pressure  upon  the  skin  with  the  finger,  or  by  placing  upon  the  part  to  be 
tested  a  rather  large  coin  at  the  temperature  of  the  body  and  gradually 
adding  more  coins,  and  noting  whether  the  patient  is  able  to  distinguish 
slight  differences  in  weight.  In  making  this  examination  the  arms  and  the 
legs  should  be  supported  upon  a  firm  base.  The  sense  of  localization  con- 
sists in  the  ability  of  the  patient  to  designate  correctly  tlie  points  upon  the 
skin  touched  or  to  indicate  them  with  his  finger.  In  addition,  it  includes 
the  recognition  of  the  area  of  contact.  The  latter  is  determined  by  means 
of  a  pair  of  compasses  or  an  esthesiometer  (Figs.  73  and  74).  In  using 
either  instrument,  two  movable  points  are  applied 
simultaneously  to  the  skin.  The  degree  of  separation 
f'CiiJ  _     of  the  points  can  be  varied.     The  size  of  the  tactile 

area  consists  in  the  smallest  distance  between  the 
points  at  which  the  two  are  appreciated  not  as  one,  but 
as  two.     Examination  of  the  time-sense  is  of  little  value. 


B& 


J, ..I., ..].,.. uem 


Fig.  73— Compasses  for 
testing  sensibility. 


Fig.  ~i. — Esthesiometer. 

It  is  made  by  means  of  vibrating  cords,  on  the  sound- 
ing-board of  which  a  healthy  individual  is  capable 
of  di.stinguishing  the  discontinuity  of  1500  vibrations 
per  second.  An  adequate  method  for  testing  the  tevi- 
perature-sense  for  practical  purposes  consists  in  blowing 
upon  the  skin  and  then  breathing  upon  the  skin,  or  by 
the  application  of  test-tubes,  one  of  which  is  gently 
warmed  in  the  flame.  Paradoxic  disturbances  of  the 
temperaiure-sense  are  manifested  at  times  in  the  confusion  of  hot  with  cold, 
and  vice  versa.  For  testing  the  sense  of  pain,  needle-prick  and  the  pulling 
of  hairs  are  sufficient.  The  electric  sensibiliti/  of  the  s/:in  is  tested  by  means 
of  a  dry  metallic  electrode  connected  with  a  faradic  current,  and  the  aji- 
preciation  of  the  beginning  prickling  must  be  separated  from  the  actual 
perception  of  pain.  The  sensation  of  tickling  and  of  itching  can  be  readily 
excited  by  touch  with  the  finger  upon  the  sole  of  the  foot,  the  palm  of  the 
hand,  in  the  axillary  cavity,  etc. 

Cutaneous  anesthesia  results  from  disease  of  either  the  periph- 
eral receptive  apparatus  (sensory  nerve-termination)  or  the  periph- 
eral   sensory    nerve-trunks,  thus    the    conducting    apparatus    for 


ANESTHESIA  527 

sensory  stimuli,  or  of  the  central  receptive  stations  in  the  spinal 
cord  or  the  brain,  and  it  is  by  no  means  always  easy  to  determine 
the  seat  of  the  disease  with  certainty.  The  demonstration  of 
peripheral  injuries  to  the  skin  itself  or  to  the  peripheral  nerve- 
trunks  is  of  particular  importance  in  this  connection.  In  addition, 
a  study  of  the  reflex  processes  is  of  great  importance,  as  these  are 
abolished  in  the  presence  of  peripheral  anesthesia,  whereas  they 
persist  if  the  anesthesia  is  of  central  origin.  As  many  nerve- 
trunks  are  of  mixed  character,  it  should  not  be  surprising  that 
often  motor  paralysis  and  anesthesia  occur  in  association. 

etiology. — The  causes  for  cutaneous  anesthesia  include  the 
same  agencies  as  give  rise  to  paralysis  and  neuralgia,  and,  accord- 
ingly, a  distinction  can  be  made  between  refrigeratory,  traumatic, 
toxic,  and  infectious  cutaneous  anesthesia,  to  which  vasomotor  anes- 
thesia may  be  added.  That  cutaneous  anesthesia  may  result  from 
exposure  to  intense  cold  is  indicated  by  the  action  of  the  ether- 
spray,  which  is  employed  upon  the  skin  to  render  minor  operations 
painless.  The  skin  becomes  anesthetic  also  when  more  consider- 
able portions  of  the  extremities  are  frozen.  Traumatic  cutaneous 
anesthesia  occurs  when  a  sensory  nerve  is  compressed  or  contused. 
Toxic  cutaneous  anesthesia  develops,  for  instance,  when  strong  alka- 
lies or  acids  are  applied  to  the  skin.  Cutaneous  anesthesia  occurs 
also  as  a  result  of  the  action  of  lead  and  of  carbon  monoxid. 
Narcotics  (morphin,  cocain)  may  likew^ise  diminish  the  sensibility 
of  the  skin.  Infectious  cutaneous  anesthesia  develops  in  the 
sequence  of  infectious  diseases  when  inflammation  of  a  sensory 
nerve  has  occurred. 

Preservation  of  cutaneous  sensibility  depends  further  upon 
normal  circulation  of  the  blood,  and  the  influence  of  cold,  already 
mentioned,  is  probably  due  in  part  to  resulting  circulatory  altera- 
tions. At  times,  however,  such  vasomotor  cutaneous  anesthesia 
develops  spontaneously  in  consequence  of  spasm  of  the  muscular 
coat  of  the  vessels.  Cutaneous  anesthesia  develops  also  after 
ligation  of  the  extremities  to  the  degree  of  pulselessness,  and  in 
conjunction  with  the  occurrence  of  embolism  or  thrombosis  of 
the  main  artery  of  an  extremity  and  with  thrombosis  of  the 
principal  vein. 

Cutaneous  anesthesia  can  be  readily  demonstrated  by  means  of 
the  tests  already  described. '  The  patient  becomes  conscious  of  the 
condition  from  his  failure,  in  the  presence  of  anesthesia  in  the 
hands,  to  feel  a  body  grasped  with  these  members,  and  which, 
therefore,  he  readily  permits  to  fall,  particularly  if  the  guidance 
of  the  eyes  is  removed.  Individuals  with  cutaneous  anesthesia  iu 
the  feet  are  not  distinctly  conscious  of  the  resistance  of  the  floor 
in  Avalking.  As  a  result,  the  gait  may  become  imcertain  and  awk- 
ward. The  patient  walks  with  the  feet  held  far  apart,  swinging 
them  in  walking,  raising  them  unduly  high,  and  he  presents  an  ataxic 


528  NERVOUS  SYSTEM 

gait — peripheral  pseudotabes.  Anesthesia  of  the  skin  and  the 
trunk  is  attended  with  failure  on  the  part  of  the  patient  to  appre- 
ciate the  presence  of  his  clothing  as  well  as  the  resistance  of  chairs 
or  beds.  Whether  the  condition  is  one  of  para-anesthesia,  hemi- 
anesthesia, or  anesthesia  of  an  entire  extremity  or  of  only  a  single 
nerve,  can  be  readily  determined  from  the  extent  of  the  impair- 
ment of  sensibility. 

Symptoms. — At  times  there  may  be  paresthesia  in  addition 
to  cutaneous  anesthesia,  including  a  sense  of  tingling,  of  cold,  and 
of  stiffness.  Some  patients  also  complain  of  severe  pain  in  the 
insensitive  areas — dolorose  anesthesia.  This  phenomenon  may  be 
explained  by  the  fact  that,  for  instance,  a  tumor  by  pressure  may 
interrupt  the  conductivity  of  a  sensory  nerve,  while,  at  the  same 
time,  the  central  termination  of  the  nerve  is  irritated,  and  this  irri- 
tation gives  rise  to  pain,  which,  in  accordance  wdth  the  law  of 
eccentric  conduction,  is  referred  to  the  peripheral  distribution  of 
the  nerve.  Often  motor,  vasomotor,  and  trophic  disorders  occur 
when  cutaneous  anesthesia  is  dependent  upon  disease  of  a  mixed 
nerve. 

The  prognosis  and  the  duration  of  the  disorder  vary  with  the 
nature  of  the  causative  condition. 

In  the  treatment  of  cutaneous  anesthesia,  in  addition  to 
removal  of  the  causative  factors — causal  therapy — cutaneous  irri- 
tation plays  an  important  part.  This  may  be  effected  by  means  of 
spirituous  aj^plications  (spirit  of  mustard,  camphorated  spirit,  spirit 
of  formic  acid,  compound  spirit  of  angelica)  or  the  electric  brush 
of  a  faradic  current  or  the  kathode  of  a  galvanic  current. 

TRIGEMINAL  ANESTHESIA. 

Ktiology. — Peripheral  trigeminal  anesthesia  occurs  prin- 
cipally as  a  result  of  exposure  to  cold  and  of  injury. 

Punctured  and  incised  wounds,  neoplasms,  and  disease  of  the 
cranial  bones  are  well  adapted  to  cause  trigeminal  anesthesia.  At 
times  the  condition  is  dependent  upon  abnormal  conditions  at  the 
base  of  the  skull  (tumors,  aneurysms,  meningitic  thickening),  which 
exert  compression  upon  and  cause  paralysis  of  the  trunk  of  the 
trigeminal  nerve.  Under  these  conditions  not  individual,  but  all 
of  the  branches  of  the  trigeminal  nerve  are  involved  in  the  anes- 
thesia, and  motor  trigeminal  paralysis  (paralysis  of  the  masticatory 
muscles)  may  be  superadded. 

Symptoms  and  Diagnosis. — Unilateral  trigeminal  anes- 
thesia is  attended  with  loss  of  cutaneous  sensibility  upon  one 
side  of  the  face  and  tlio  anterior  aspect  of  the  auricle.  When  a 
glass  or  a  spoon  is  carried  to  the  mouth  a  sensation  is  perceived 
as  if  these  objects  were  divided  at  the  middle  line,  because  one- 
half  of  the  lip  is  insensible.     Sensation  is  lost  also  upon  the  con- 


DISEASE  OF  THE  OLFACTORY  NERVE  529 

junctiva,  the  cornea,  and  the  nasal  and  buccal  mucous  membrane. 
Touching  the  eye  causes  no  movement  of  the  lid  and  no  flow 
of  tears  through  reflex  influences.  The  secretion  of  tears  is 
diminished.  Tickling  the  nose  upon  the  diseased  side  does  not 
excite  sneezing.  Pungent  olfactory  impressions  (ammonia,  acetic 
acid)  also  are  not  appreciated.  The  sensibility  of  the  buccal 
mucous  membrane  likewise  is  lost  upon  one  side.  The  sense  of 
taste  is,  as  a. rule,  abolished  upon  the  anterior  two-thirds  of  the 
tongue.  At  times  unilateral  coating  of  the  tongue  and  diminuticm 
in  the  secretion  of  saliva  have  been  observed.  The  facial  expression 
is  frequently  characterized  by  relaxation  upon  the  diseased  side, 
because  the  trigeminal  nerve  exercises  a  reflex  influence  upon  the 
tone  of  the  facial  muscles.  Vasomotor  and  particularly  trophic 
disorders  also  occur.  Among  the  latter  inflammation  of  the  cornea 
and  of  the  whole  eye — neuroparalytic  ophthalmia — has  long  been 
known,  although  of  late  there  is  a  growing  tendency  to  adopt  the 
view  that  this  inflammation  of  the  eye  is  not  dependent  upon  the 
influence  of  trophic  nerve-fibers,  but  that  in  consequence  of  defi- 
cient sensibility  of  the  cornea  winking  is  infrequent,  so  that  foreign 
bodies  from  the  air,  and  particularly  bacteria,  remain  upon  the  eye 
and  cause  inflammation. 

Peripheral  is  diiferentiated  from  central  trigeminal  anesthesia 
by  the  unaltered  persistence  of  the  reflexes  with  the  latter. 

Prognosis. — The  prognosis  depends  upon  the  curability  of 
the  causative  condition. 

Treatment. — The  treatment  should  be  conducted  according 
to  the  rules  given  on  p.  528.  In  addition,  the  eye  should  be  pro- 
tected by  means  of  a  suitable  bandage. 

PERIPHERAL  DISEASE  OF  THE   NERVES  OF 
SPECIAL  SENSE. 

DISEASE  OF  THE  OLFACTORY  NERVE. 

Peripheral  disease  of  the  olfactory  nerve  is  attended  either  with 
morbidly  increased  acuity  of  the  sense  of  smell — hyperosmia — or 
with  diminution  and  even  loss  thereof — hyposmia  and  anosmia,  or 
with  jmrosmia;  that  is,  subjective  appreciation  of  odors  in  the 
absence  of  odorous  substances. 

Hyperosmia  is  generally  of  central  origin,  and  occurs  with  par- 
ticular frequency  in  association  with  hysteria.  Patients  thus  af- 
fected are  capable  of  smelling  substances  that  another  with  normal 
olfactory  organs  is  incapable  of  appreciating ;  or  they  arc  greatly 
annoyed  by  olfactory  impressions  of  not  excessive  intensity,  and 
at  times  are  seized  with  excitement,  convulsions,  or  syncope. 

Hyposmia  and  anosmia  are  common  accompaniments  of  acute 
and  chronic   inflammation  of  the   nasal    mucous  membrane.     The 

34 


530  NERVOUS  SYSTEM 

condition  has  been  frequently  observed  also  in  connection  with 
nasal  polvpi.  It  often  develo])s  in  the  sequence  of  protracted 
ether-inhalation,  as,  for  instance,  in  collectors  of  insects.  It  may 
occur  as  a  result  of  traumatic  influences  in  the  presence  of  tumors 
of  the  ethmoid  bone  from  pressure  upon  the  fibers  of  the  olfactory 
nerve  or  in  the  presence  of  fracture  of  the  ethmoid  bone  or  the 
skull.  Tumors  and  menino-itic  thickenintj  at  the  base  of  the  skull, 
as  well  as  tumors,  hemorrhage,  and  softening  in  the  frontal  region 
of  the  brain  close  to  the  islandofReil,  may  cause  anosmia  through 
pressure  upon  or  injury  of  the  olfactory  nerve.  At  times  anosmia 
develops  in  advanced  life,  in  consequence  of  involution  of  the 
olfactory  bulb.  Further,  anosmia  may  be  congenital  in  conse- 
quence of  absence  of  the  olfactory  nerves.  The  condition  may  be 
unilateral  or  bilateral,  and  in  many  persons  is  detected  purely  by 
accident.  Bilateral  loss  of  the  sense  of  smell  is  attended  with  dis- 
turbance in  the  sense  of  taste  for  all  such  articles  of  food  and  drink 
whose  taste  is  dependent  on  their  aroma. 

Parosmia  is  frequently  of  central  origin  (mental  disease,  hysteria, 
epilepsy),  although  it  may  also  occur  as  a  result  of  peripheral  in- 
fluences, in  connection  with  acute  and  chronic  inflammation  of  the 
nasal  mucous  membrane.  The  condition  generally  found  is  one 
of  a  sense  of  disagreeable  olfactory  impressions  (caxiosniki),  which 
not  rarely  gives  rise  to  hallucinations  in  the  insane.  At  times 
parosmia  is  associated  with  anosmia,  a  condition  corresponding 
with  painful  anesthesia  and  susceptible  of  a  similar  explanation ; 
that  is,  interruption  of  conduction  on  the  one  hand,  and  stimula- 
tion of  the  central  extremity  of  the  olfactory  nerve  on  the  other 
hand.  Disturbances  of  the  sense  of  smell  can  be  tested  with  the 
aid  of  pleasantly  smelling  (oil  of  cloves,  oil  of  rose)  and  disagree- 
bly  smelling  substances  (assafetida),  as  the  disorder  may  be  partial 
and  not  complete.  Pungent  odors  (ammonia,  acetic  acid)  should 
be  avoided,  as  this  variety  of  olfactory  impressions  is  transmitted 
through  the  trigeminus.  First  one  naris  and  then  the  other  is 
tested,  while  the  nasal  orifice  not  being  examined  is  carefully 
closed. 

The  treatment  of  all  varieties  of  olfactory  disturbance  con- 
sists essentially  in  efiPorts  to  cure  the  fundamental  disorder. 

DISEASE  OF  THE  GUSTATORY  NERVR 

Disorders  of  the  sense  of  taste  on  the  anterior  two-thirds  of  the 
tongue  are  dependent  upon  disease  of  either  the  trigeminal  or  the 
facial  nerve,  while  those  on  the  posterior  third  are  dependent  upon 
disease  of  the  glossopharyngeal  nerve.  Further,  it  is  also  con- 
tended that  the  fibers  for  the  sense  of  taste  from  the  trigeminal 
nerve  are  derived  from  the  trunk  of  the  glossopharyngeal  nerve. 
That  the  facial  nerve   itself  contains  no  nerves  of  taste,  but  that 


DISORDERS  OF  THE  PERIPHERAL  ^'ERVES  531 

these  pass  at  intervals  from  the  trunk  of  the  trigeminal  nerve  into 
that  of  the  facial  nerve  has  already  been  mentioned  on  pp.  479  and 
487  in  the  consideration  of  peripheral  facial  palsy.  The  morbid 
disorders  of  the  sense  of  taste  are  manifested  in  a  manner  anal- 
ogous to  those  of  the  sense  of  smell,  and  they  are  designated  hy- 
pergeusia,  hypogeusia,  and  parageusia. 

Hypergeusia  consists  in  an  ability  to  detect  the  taste  of  sub- 
stances even  when  present  in  small  amounts.  More  pronounced 
gustatory  impressions  may  give  rise  to  conditions  of  excitement, 
convulsions,  or  syncope.  Hypergeusia  is  generally  of  central 
origin,  and  is  encountered  with  particular  frequency  in  association 
with  hysteria. 

Hypogeusia  and  ageusia  involving  the  anterior  two-thirds  of  the 
tongue  is  most  commonly  unilateral  in  association  with  peripheral 
facial  jJcdsy  if  the  lesion  is  situated  between  the  geniculate  gan- 
glion and  the  giving  oif  of  the  chorda  tympani  nerve.  In  other 
instances  unilateral  hypogeusia  or  ageusia  is  observed  in  associa- 
tion with  trigeminal  anesthesia  or  with  injuries  of  the  lingual 
nerve.  Finally,  the  condition  may  involve  the  posterior  third  of 
the  tongue  in  the  presence  of  disease  of  the  glossopharyngeal  nerve. 
Persons  with  a  heavily  coated  tongue  often  complain  of  impair- 
ment of  the  sense  of  taste,  or  this  may  develop  after  the  ingestion 
of  food  that  is  unduly  hot  or  irritating. 

Parageusia  is  observed  principally  as  a  result  of  central  causes, 
in  the  insane  and  the  hysterical.  The  patient  generally  complains 
of  a  bad  taste,  although  the  mouth  is  empty. 

The  tests  for  the  sense  of  taste  are  described  on  p.  483. 

The  treatment  of  disorders  of  the  sense  of  taste  is  comprised 
in  the  relief  of  the  primary  disorder. 

INFLAMMATORY  AND  DEGENERATIVE  DIS- 
ORDERS OF  THE  PERIPHERAL  NERVES. 

PRELIMINARY   CONSIDERATIONS. 

Inflammatory  and  degenerative  disorders  of  the  peripheral 
nerves  are  generally  designated  neuritis.  It  should,  however,  be 
borne  in  mind  in  this  connection  that  inflammatory  processes  are 
by  no  means  always  operative,  but  it  is  difficult  anatomically  to 
make  a  sharp  distinction  between  nerve-inflammation  and  nerve- 
degeneration.  Nevertheless,  neuritis  plays  a  most  important  part 
at  present  in  the  domain  of  nervous  diseases. 

!^tiology. — The  causes  for  inflammatory  and  degenerative 
disorders  of  the  peripheral  nerves  are  exposure  to  cold,  traumatism, 
infection,  and  intoxication.  To  what  extent  bacteria  are  concerned 
in  these  processes  is  as  yet  undetermined.  It  is  highly  probable 
that  cold  and  injury  act  only  as  contributory  influences  for  infec- 


532  NERVOUS  SYSTEM 

tion  of  peripheral  nerves  ■with  bacteria,  while  in  the  development 
of  infectious  and  toxic  neuritis  the  injurious  influence  of  toxins 
(bacterial  poisons)  or  chemic  poisons  upon  the  nervous  structures 
may  be  operative. 

The  anatomic  alterations  involve  eitlier  the  interstitial 
connective  tissue  of  the  nerves — interstitial  iieuritiii — or  the  nerve- 
fibers  themselves — parenchymatous  neuritis.  In  addition,  mixed 
varieties  of  the  two  principal  classes  mentioned  occur — mixed 
neuritis;  and  these  again  may  be  separated  into  several  subdivisions 
accordingly  as  the  connective  tissue  and  the  nervous  structure  are 
affected  simultaneously  by  the  inflammatory  irritant  or  the  inflam- 
matory process  begins  in  one  portion  of  the  nerve  and  then  in- 
volves the  other  secondarily. 

Interstitial  neuritis  in  its  acute  form  is  often  indicated  macro- 
scopically  by  the  thickened  and  unusually  reddened  appearance 
of  the  nerve,  with  loss  of  its  transverse  striation  (bands  of  Fon- 
tana).  Here  and  there  extravasations  of  blood  may  have  taken 
place,  and  these  may  be  present  both  in  the  external  nerve-sheath 
and  upon  transverse  section  of  the  nerve.  The  presence  of  numer- 
ous extravasations  of  blood  has  given  rise  to  the  designation  Jiem- 
orrhagic  or  apoplectiform  neuritis.  On  microscopic  examination  of 
the  nerve  the  blood-vessels  are  found  greatly  dilated,  tortuous, 
and  distended  with  blood.  Tlieir  walls  often  appear  thickened 
and  swollen  and  glistening.  The  nuclei  of  the  vessel-wall  are  in 
places  increased  in  number  and  involved  in  fatty  degeneration. 
In  addition,  the  interstitial  connective  tissue  is  increased.  At  the 
same  time  it  contains  numerous  cells  and  round  cells. 

In  rare  cases  an  accumulation  of  pus  takes  place  in  the  nerve — suppu- 
rative neuritis.  This  may  occur  particularly  when  foreign  bodies  and  toxic 
substances  have  penetrated  into  the  nerve,  and  also  when  suppurative  in- 
flammation in  the  neighborhood  of  the  nerve  has  extended  to  the  latter. 

In  the  presence  of  chronic  interstitial  neuritis  the  nerve  fre- 
quently presents  a  brownish,  almost  black  color,  due  to  the  remains 
of  pigment  from  preceding  hemorrhage.  The  nerve  generally 
feels  denser  than  normal,  in  correspondence  with  an  increase  in 
the  interstitial  connective  tissue.  At  times  the  inflammatory 
areas  appear  as  nodular  enlargements — nodose  neuritis.  It  is  note- 
worthy that  a  neuritis  by  no  means  always  extends  throughout  the 
entire  course  of  a  nerve,  but  involves  only  a  single  small  portion 
or  several  portions,  and  accordingly  a  distinction  should  be  made 
between  diffuse,  circvmsrrihed,  and  multiple  or  insular  neuritis. 
The  neighborhood  of  joints  and  the  points  of  deflection  of  nerves 
constitute  especially  favored  situations  for  insular  neuritis.  At 
times  a  neuritis  that  is  at  first  insular  exhibits  a  tendency  to  ex- 
tend progressively  in  tlie  course  of  the  nerve,  and  even  to  the 
spinal  cord,  and  the  condition  is  then  designated  migratory  neuritis. 

Parenchymatous  neuritis  can  be  diagnosed    with  certainty  by 


DISORDERS  OF  THE  PERIPHERAL  NERVES  533 

means  of  microscopic  examination.  In  teased  preparations  of 
fresh  nerve-tissue  or  in  such  tissue  stained  with  osmic  acid  fibers 
will  be  found  whose  medullary  substance  and  axis-cylinder  appear 
granular  and  involved  in  fatty  degeneration,  and  often  also  ab- 
sorbed, so  that  the  empty  nerve-sheath  remains.  In  the  latter 
multiplication  of  the  nuclei  takes  place.  On  transverse  section  of 
hardened  nerves  empty  sheaths  will  be  found  in  greater  or  lesser 
number,  and  frequently  containing  but  a  single  nucleus. 

French  physicians  have  pointed  out  that  parenchymatous  neuritis  also 
at  times  involves  the  nerve-fibers  for  only  short  distances,  and  this  condi- 
tion has  been  designated  segmental  neuritis. 

The  symptoms  of  neuritis  will  naturally  vary  accordingly  as 
the  inflammatory  process  involves  motor,  sensory,  or,  as  occurs 
most  commonly,  mixed  nerves.  At  the  beginning  of  the  disease 
irritative  symptoms  are  not  rarely  present,  but  these  are  shortly 
followed  by  paralytic  phenomena.  Therefore,  infiammation  of 
motor  nerves  is  often  at  first  attended  with  twitching  and  rigidity 
in  the  related  muscles,  but  these  are  soon  replaced  by  progress- 
ively increasing  weakness  and  paralysis.  The  muscles  rapidly 
undergo  wasting,  as  they  participate  in  the  degenerative  process, 
and  together  Avith  the  diseased  nerves  are  generally  tender  upon 
pressure.  Both  nerve  and  muscle  exhibit  degenerative  electric 
reaction.  In  the  distribution  of  the  diseased  nerves  the  tendon- 
reflexes  are  at  times  increased  at  first,  but  generally  diminution 
and  disappearance  of  reflex  movement  soon  occur.  After  neuritic 
muscular  paralysis  has  existed  for  some  time  muscular  contrac- 
tures and  deformities  readily  develop. 

Infiammation  of  sensory  nerves  is  attended  with  especial  fre- 
quency with  paresthesias :  a  sense  of  coldness  or  the  creeping  of 
ants  (formication),  prickling  and  sticking  of  the  skin,  marked 
neuralgic  pains.  Often  cutaneous  hyperesthesir  is  present  at  the 
beginning  of  the  disorder,  but  this  subsequently  is  replaced  by 
anesthesia. 

In  cases  of  infiammation  of  mixed  nerves,  in  addition  to  the 
motor  and  sensory  disturbances  described,  vasomotor  and  trophic 
disturbances  are  at  times  observed,  as,  for  instance,  pallor  or  cyan- 
otic discoloration  of  the  skin,  accordingly  as  an  irritative  or  a 
paralytic  condition  of  the  vasomotor  nerves  is  present,  coldness  of 
the  skin,  hyperidrosis  or  anidrosis,  thickening  of  the  epidermis, 
abnormally  increased  desquamation  of  the  epidermis,  excessive 
growth  of  hair,  thickening  and  fragility  of  the  nails,  glossy  fin- 
ger, herpes  or  pemphigus-like  cutaneous  eruptions,  articular 
swelling,  etc. 

The  course  of  a  neuritis  may  be  acute,  subacute,  or  chronic. 
Acute  neuritis  at  times  sets  in  abruptly — aj)oplectiform  neuritis. 
In  other  instances  it  develops,  like  an  acute  infectious  disease, 


534  NERVOUS  SYSTEM 

with  rigor,  fever,  and  enlargement  of  tlie  spleen.  Chronic  neuritis 
may  result  from  an  acute  neuritis  or  it  may  develop  insidiously  in 
an  independent  manner.  At  times  neuritis  begins  first  in  a  single 
nerve  or  in  a  few  nerves,  and  then  extends  progressively  to  a 
larger  number — polyneuritis.  Under  such  circumstances  it  may 
happen  that  the  alterations  are  first  observed  in  the  nerves  of  the 
lower  extremity,  gradually  invading  nerves  at  successively  higher 
levels — ascending  neuritis.  Should  cereijral  nerves  also  become 
involved,  the  disease  becomes  a- serious  one,  and  death  may  readily 
take  place  in  consequence  of  paralysis  of  the  vagus-accessory 
nerve.  Even  when  cerebral  nerves  are  not  involved  neuritis  is  a 
serious  disease  in  relation  to  its  curability.  While  recovery  is 
always  possible,  it  is  not  certain,  and  under  all  circumstances 
much  patience  is  necessary  on  the  part  of  both  patient  and  phy- 
sician. 

The  diagnosis  of  neuritis  is  not  particularly  difficult.  Inflam- 
mation of  motor  nerves  is  most  likely  to  be  confounded  with  ante- 
rior poliomyelitis,  for  in  this  disease  also,  as  the  lesion  of  the 
motor-trophic  ganglion-cells  in  the  anterior  horns  of  the  spinal 
cord  is  soon  associated  with  degeneration  of  the  related  nerves  and 
muscles,  degenerative  muscular  atrophy  and  degenerative  electric 
reaction  occur ;  but  poliomyelitis  is  unattended  with  sensory  dis- 
turbances, and  the  diseased  nerves  and  muscles  are  also  usually 
free  from  pain  on  pressure.  Neuritis  is  distinguished  from  other 
diseases  of  the  spinal  cord  by  the  fact  that  the  liladder  and  the 
rectum  are  almost  always  uninvolved  witli  the  former,  while,  on 
the  other  hand,  nerve  and  muscle  exhibit  degenerative  electric 
reaction. 

The  treatment  of  neuritis  should  be  directed,  in  the  first  place, 
to  the  causative  factors — causal  therapy.  In  a  case  of  refrigeratory 
neuritis,  for  instance,  warm  baths,  salicylic  acid,  sodium  salicylate, 
also  diaphoretics  (pilocarpin  hydrochlorate)  Avill  be  employed. 
Causal  indications  may  be  present  also  in  a  case  of  traumatic 
neuritis.  Antecedent  syphilis  will  require  the  employment  of 
mercurial  preparations  and  potassium  iodid,  and  the  like.  The 
symptomatic  treatment  is  the  same  as  that  in  cases  of  peripheral 
paralysis  (p.  475)  and  of  cutaneous  anesthesia  (p.  528).  Baths, 
salicylates,  antipyrin,  massage,  and  electricity  are  the  most  impor- 
tant remedies. 

MULTIPLE  NEURITIS, 

Ktiology. — ^Multiple  neuritis,  also  known  as  polyneuritis, 
occurs  at  times  like  an  independent  infectious  disease,  and  is  then 
often  referred,  as  a  matter  of  convenience,  to  exposure  to  cold, 
the  occurrence  of  which,  however,  cannot  be  confirmed  on  careful 
inquiry.     At  times  cases  of  such  infectious  polyneuritis  have  been 


MULTIPLE  NEURITIS  535 

observed  to  occur  in  groups  and  in  almost  epidemic  distribution. 
It  must,  nevertheless,  be  admitted  that  exposure  to  cold  may  be 
followed  by  multiple  neuritis,  at  least  in  the  sense  that  the  exposure 
favors  infection  of  peripheral  nerves.  At  times  multiple  neuritis 
has  been  observed  to  develop  in  the  sequence  of  traumatism,  which 
at  times  has  been  of  apparently  insignificant  character,  as,  for 
instance,  riding  upon  rough  roads.  Multiple  neuritis  occurs  with 
particular  frequency  in  the  sequence  of  infectious  diseases.  It  has 
long  been  known  and  greatly  feared  in  connection  with  pharyngeal 
diphtheria,  but  it  may  occur  also  in  conjunction  with  typhoid 
fever,  herpes  zoster,  dysentery,  pneumonia,  pulmonary  tubercu- 
losis, and  particularly  syphilis.  Septic  diseases,  and  particularly 
puerperal  fever,  at  times  give  rise  to  multiple  neuritis.  A  com- 
plete description  of  toxic  multijAe  neuritis  will  not  be  attempted 
here,  because  it  will  be  taken  up  in  detail  in  succeeding  sections. 
On  the  other  hand,  attention  is  to  be  directed  to  the  occurrence  of 
multiple  neuritis  in  consequence  of  auto-intoxication.  This  condi- 
tion is  observed  in  connection  with  diabetes  mellitus  and  gout,  and 
possibly  also  cases  of  marasmus  belong  in  this  category,  as,  for 
instance,  in  association  with  carcinoma.  With  the  exception  of 
post-diphtheric  paralysis,  multiple  neuritis  is  generally  a  disease 
of  adults. 

Anatomic  Alterations. — Multiple  neuritis  may  be  of  inter- 
stitial, parenchymatous,  or  mixed  character,  and  nothing  need  be 
added  to  what  has  been  stated  on  p.  532  concerning  neuritis  in 
general. 

Symptoms  and  Diagnosis. — Multiple  neuritis  may  pursue 
an  acute  or  a  chronic  course.  If  it  occurs  as  an  independent  acute 
infectious  disease,  it  sets  in  at  times  with  a  chill,  followed  by  ele- 
vation of  temperature  to  as  high  as  40°  C.  (104°  F.),  and  even 
higher.  Often  enlargement  of  the  spleen  is  present.  Above  all, 
paralysis  occurs,  generally  involving  isolated  nerves  of  the  lower 
extremities  at  first,  soon  rendering  the  entire  extremity  helpless, 
and  then  extending  to  the  upper  extremities.  Cerebral  nerves 
also  may  be  involved.  Paralysis  of  the  vago-accessory  nerve  is 
attended  with  great  acceleration  of  pulse.  Paralysis  of  degluti- 
tion may  occur.  At  times  paralysis  of  the  hypoglossal  and  facial 
nerves  has  been  observed.  On  one  occasion  I  observed  sudden 
blindness  in  consequence  of  inflammation  of  the  optic  nerve.  By 
reason  of  the  ascending  character  of  the  paralysis  the  disease  is 
strongly  suggestive  of  acute  ascending  spinal  paralysis,  but  in 
cases  of  multiple  neuritis  the  paralyzed  nerves  and  muscles  ex- 
hibit, in  contradistinction  from  spinal  paralysis,  degenerative  elec- 
tric reaction.  In  addition,  nerves  and  muscles  are  generally 
tender  on  pressure,  and  the  paralyzed  muscles  soon  undergo  de- 
generative atrophy.  Sensory  disturbances  are  frequently  present. 
Vasomotor  and  trophic  disturbances  (coldness  and  cyanotic  dis- 


636  NERVOUS  SYSTEM 

coloration  of  the  skin,  edema,  articular  swelling)  also  are  observed. 
At  times  active  delirium  appears,  and  the  patient  may  die  in  coma. 
The  bladder  and  the  rectum  are,  as  a  rule,  uninvolved.  In  some 
instances  I  have  observed  recovery  from  acute  multiple  neuritis, 
although  after  a  considerable  time  a  second  and  even  a  third 
attack  occurred — recurrent  polyneuritis. 

Chronic  multiple  )ieurifis  is  often  unattended  with  fever,  but  in 
other  instances  periodic  febrile  movement  occurs.  The  paralysis 
develops  slowly  in  the  course  of  weeks  or  months,  and  at  times 
exhibits  also  an  ascending  character.  The  disease  may  be  readily 
confounded  with  chronic  anterior  poliomyelitis,  as  in  this  disease 
also  degenerative  electric  reaction  is  found  in  the  paralyzed 
muscles,  but  it  is  unattended  with  sensory  disturbances,  and  the 
nerves  and  muscles  are  not  tender  to  touch.  In  some  cases  chronic 
multiple  neuritis  originates  from  an  acute  neuritis,  the  fever  ceas- 
ing and  the  new  paralysis  developing  but  slowly.  Long-continued 
paralysis  is  frequently  attended  with  contractures  that  give  rise 
to  deformities  in  the  extremities. 

Prognosis. — The  prognosis  of  multiple  neuritis  is  always 
serious.  If  the  disease  pursues  an  ascending  course,  there  will  be 
danger  of  death  from  paralysis  of  cerebral  nerves.  In  the  pres- 
ence of  chronic  multiple  neuritis  a  long  time  may  be  expected  to 
elapse  before  the  diseased  nerves  will  be  regenerated  and  the 
paralysis  will  have  disappeared. 

Treatment. — The  treatment  of  multiple  neuritis  should  be 
conducted  upon  the  lines  laid  down  on  p.  475. 

TOXIC  NEURITIS. 

SATURNINE   PARALYSIS. 

Ktiologfy. — Of  the  toxic  varieties  of  neuritis,  that  due  to  lead- 
poisoning  lias  been  known  longest.  It  occurs  most  commonly  in 
certain  artisans  who  in  the  pursuit  of  their  avocation  are  exposed 
to  chronic  lead-poisoning.  Among  these  are  particularly  painters, 
potters,  printers,  file-cutters,  shot-molders,  workmen  in  lead-mines, 
etc.  Lead-poisoning  may  result  accidentally  from  the  use  of  pre- 
.served  food  kept  in  receptacles  containing  lead,  of  Avater  trans- 
mitted through  lead-pipes,  of  cosmetics  containing  lead,  of  snuff 
wrapped  in  lead-foil,  etc.  Rarely,  lead-poisoning  may  result  from 
carelessness  on  the  part  of  the  physician  in  consequence  of  the 
administration  of  preparations  of  lead  in  too  large  amounts  or  for 
too  long  a  period. 

Symptoms  and  Diagnosis. — The  symjitoms  of  saturnine 
paralysis  usually  appear  only  after  the  patient  has  been  exposed 
to  the  action  of  the  metal  for  a  considerable  length  of  time.  As 
a  rule,  other  symptoms  of  lead-poisoning  have  already  been  pres- 


TOXIC  NEURITIS  537 

ent,  particularly  the  presence  of  a  bluish-gray  lead-line  at  the 
margin  of  the  gums,  together  with  anemia  and  colic.  Bilateral 
radial  paralysis,  with  preservation  of  the  function  of  the  supinators, 
is  distinctive  of  lead-paralysis.  The  palsy  generally  develops 
gradually,  and  the  patient  complains  at  first  of  weakness  in  the 
hands  and  fingers,  which  eventually  passes  over  into  paralysis, 
and  in  spite  of  all  devices  renders  the  hand  incapacitated  for 
work.  When  the  forearms  are  held  horizontally  the  hands  fall 
in  palmar  flexion,  and  at  the  same  time  the  fingers  are  flexed  and 
the  thumbs  adducted.  Dorsal  flexion  of  the  hands,  extension  of 
the  fingers,  abduction  and  extension  of  the  thumb,  abduction  and 
adduction  of  the  hands  toward  the  ulna  or  the  radius,  can  be 
effected  imperfectly,  if  at  all.  Of  the  extensors  of  the  fingers, 
those  of  the  index-finger  and  the  little  finger  are  involved  late,  so 
that  both  of  these  fingers  can  at  first  be  relatively  well  engaged 
in  dorsal  flexion.  Supination  and  extension  of  the  forearm  remain 
unaffected.  Only  rarely  is  lead-palsy  widespread — generalized 
lead-paralysis.  Under  such  circumstances  the  muscles  of  the 
upper  arm,  the  shoulder,  the  back,  and  the  lower  extremities 
also  may  be  involved.  Even  the  muscles  of  the  face  and  the 
larynx  and  the  diaphragm  are  at  times  paralyzed. 

The  paralyzed  muscles  become  the  seat  of  degenerative  atrophy, 
and  both  nerve  and  muscle  exhibit  degenerative  electric  reaction. 
The  tendon-reflexes  are  abolished  in  the  paralyzed  parts,  and 
gradually  muscular  eontractures  take  place.  Diseased  nerves  and 
muscles  are  generally  tender  on  pressure.  At  times  some  of  the 
tendons  become  thickened — hypertrophio  tenosynovitis.  Paresthesia 
and  hyperesthesia,  less  commonly  anesthesia,  also  occur. 

The  duration  of  the  paralysis  depends  upon  the  degree  of  the 
disturbance,  and  more  accurately  upon  the  degenerative  electric  re- 
action. Advanced  paralysis  requires  many  months  for  recover}^ 
Frequently  relapses  occur,  often  because  the  patients  resume  their 
former  employment ;  less  commonly  relapses  occur  in  spite  of 
avoidance  of  contact  with  lead. 

Anatomic  Alterations. — Upon  the  basis  of  personal  obser- 
vation I  should  consider  lead-paralysis  the  consequence  of  a 
degenerative  inflammation  of  j^eripheral  nerves.  Paralysis  of  long 
standing  may  be  complicated  by  secondary  atrophy  of  the  related 
trophic-motor  ganglion-cells  in  the  anterior  horns  of  the  spinal 
cord.  The  paralyzed  muscles  exhibit  reduction  in  the  size  of  their 
mascle-fibers,  proliferation  of  the  sarcolemma-nuclei,  and  increase 
in  the  interstitial  connective  tissue. 

Prognosis. — Although  lead-palsy  is,  as  a  rule,  not  a  fatal 
disease,  the  prognosis  with  regard  to  permanent  recovery  is  not 
favorable,  because  patients  resume  their  injurious  pursuits  without 
observance  of  the  necessary  precautionary  measures,  or  are  even 


5138  NERVOUS  SYSTEM 

satisfied  witli  an  improvement  in  tlie  paralysis  and  return  to  their 
work  too  quickly. 

Treatment. — For  the  load-paralysis  itself  sulphur-baths  should 
be  employed  (potassium  sulphid,  150.0 — 5  ounces — to  a  full  bath 
at  a  temperature  of  28°  R. — 35°  C. — 95°  F.),  massage  of  the  para- 
lyzed muscles  be  practised,  or  instead  electric  treatment,  and  thrice 
weekly  subcutaneous  injections  of  strychnin  be  made  : 

R  Strychnin  nitrate,  0.1  {l\  grains); 

Glycerin, 

Distilled  water,  each,  5.0  (75  minims). — M. 

Dose  :  0.25  (4  minims)  subcutaneously. 

Internally  potassium  iodid  (5.0  :  200 — 75  grains  :  6|-  fluidounces ; 
15  c.c. — 1  tablespoonful — thrice  daily)  should  be  administered 
to  eliminate  the  lead  present  in  the  system.  As  a  prophylactic 
measure  it  is  important  that  the  patient  shall  never  take  a  meal  in 
the  room  in  which  lead  is  manipulated.  Also,  before  eatino;,  the 
mouth  and  the  pharynx  should  be  rinsed  with  water  to  remove 
lead-dust  that  may  be  present,  and  the  hands  should  be  freed  from 
adherent  particles  of  lead  by  washing.  Experience  has  shown 
that  drunkards  are  more  susceptible  to  lead-poi.soning  than  others. 

In  isolated  cases  jjaralysis  has  been  observed  among  those  exposed  to 
the  action  oi  mercury,  zinc,  and  copper,  and  this  also  is  in  all  probability  the 
result  of  a  degenerative  neuritis. 

ARSENICAL  PARALYSIS. 

Arsenical  paralysis  is  observed  most  commonly  after  acxde  arsen- 
ical poisoning.  The  extensor  muscles  of  the  leg,  particularly  the 
peronei,  are  generally  first  attacked,  although  the  arms — with  pref- 
erence the  extensors  of  the  forearms — may  also  be  involved.  In 
one  case  I  observed  paralysis  of  the  bladder  and  of  the  vagus. 
The  paralyzed  muscles  rapidly  undergo  wasting  and,  together 
with  the  related  nerves,  are  tender  on  pres.sure  and  yield  degen- 
erative electric  reaction.  The  tendon-reflexes  are  abolished  in  the 
distribution  of  the  paralysis.  Gradually  muscular  contractures 
develop.  Often  the  paralyzed  parts  become  the  seat  of  severe 
neuralgia.  Nevertheless,  cutaneous  anesthesia  becomes  more  and 
more  marked,  and  as  a  result  the  gait  becomes  ataxic — peripheral 
pseudotabes. 

Little  is  known  with  regard  to  the  anatomic  alterations, 
although  the  occurrence  of  a  degenerative  neuritis  is  most  prol)able. 

The  prognaosis  is  not  unfavorable,  although,  naturally,  many 
months  may  elapse  before  complete  recovery  takes  place. 

The  treatment  is  the  same  as  that  for  lead-paralysis. 

Paralysis  with  symptoms  similar  to  those  dependent  upon  plumbic  and 
arsenical  poisoning  has  been  observed  also  after  poisoning  with  phosphorus, 
carbon  monoxid,  and  carbon  disulphid. 


TOXIC  NEURITIS  539 


ALCOHOLIC  PARALYSIS. 

Htiology. — Alcoholic  paralysis  occurs  principally  in  drinkers 
of  spirit.  In  one  instance  I  have  observed  the  condition  even  in 
a  boy. 

Symptoms  and  Diagnosis. — The  paralysis  almost  always 
develops  gradually,  although  I  have  repeatedly  observed  a  sudden 
(apoplectic)  onset.  Not  rarely  the  paralysis  has  been  preceded  by 
severe  neuralgia,  which  may  also  persist  in  association  with  the 
paralysis.  The  extensors  of  the  legs  and  the  forearms  are  involved 
in  the  paralysis  earliest  and  most  constantly.  Gradually  all  of  the 
muscles  of  the  extremities  may  be  affected,  and  even  cerebral 
nerves,  particularly  the  vagus,  are  at  times  involved.  Paralysis 
of  the  bladder  and  the  rectum  is  uncommon.  The  diseased  nerves 
and  muscles  are  tender  on  pressure,  undergo  wasting,  and 
exhibit  degenerative  electric  reaction.  Contractures  slowly  de- 
velop. The  tendon-reflexes  are  abolished  in  the  paralyzed  parts. 
Cutaneous  sensibility  is  frequently  impaired  and  peripheral  pseudo- 
tabes may  readily  develop.  At  times  marked  swaying  of  the  body 
occurs  when  the  eyes  are  closed — Bracht-Romberg's  symptom.  Con- 
traction of  the  pupil — myosis — and  sluggish  reaction  to  light  may 
be  present.  Paralysis  of  the  ocular  muscles  is  uncommon.  The 
disorder  is  at  times  attended  with  slight  febrile  movement.  Pro- 
gressive alcoholic  marasmus,  often  associated  with  stupor,  occa- 
sionally leads  to  a  fatal  termination.  Two  patients  under  my 
observation  died  in  consequence  of  complicating  miliary  tuber- 
culosis. The  duration  of  the  disease  may  be  extended  over  many 
months. 

Anatomic  Alterations. — Degenerative  atrophy  of  the  nerve- 
fibers  is  found  in  the  diseased  nerves,  and  in  the  muscles  atrophy 
of  the  muscle-fibers,  increase  in  the  sarcolemma-nuclei,  and  multi- 
plication of  the  interstitial  connective  tissue.  At  times  the  degen- 
erative process  has  extended  from  the  nerves  to  the  spinal  cord, 
in  which  degenerative  areas  develop  in  the  posterior  columns  and 
atrophy  of  the  ganglion-cells  in  the  anterior  horns  takes  place. 

Prognosis. — Kecovery  from  extensive  alcoholic  paralysis  is 
wholly  possible,  but  requires  a  long  time. 

Treatment. — The  treatment  is  the  same  as  that  for  lead- 
paralysis  (p.  538).     Abstinence  from  alcohol  is  highly  important. 

At  times  paralysis  has  been  observed  after  the  ingestion  of  spoiled  rye — 
ergot-poisoning  or  ergotism — and  of  spoiled  maize — pellagra — and  this  must 
in  all  probability  be  considered  the  sequel  of  a  toxic  neuritis. 


540  NERVOUS  SYSTEM 


II.   DISEASES   OF    THE   SPINAL   CORD. 


PRELIMINARY  DIAGNOSTIC  CONSIDERATIONS. 

In  the  diagnosis  of  disease  of  the  spinal  cord  two  points  must 
be  taken  into  consideration — in  the  hrst  place,  the  seat,  ana,  in  the 
second,  the  anatomic  nature  of  the  spinal  disorder,  \yith  regard 
to  the  seat  of  the  disease  a  correct  diagnosis  is  possible  only  from 
a  knowledge  of  the  clinical  anatomy  and  physiology  of  the  spinal 
cord.  A  brief  resume  of  these  subjects  may  therefore  be  given. 
The  spinal  cord  extends  downward  to  the  junction  between  the 
first  and  the  second  lumbar  vertebra,  whence  it  follows  that  all 
foci  of  disease  below  the  second  lumbar  vertebra  may  involve  the 
Cauda  equina,  but  not  the  spinal  cord  itself.  Also,  there  is  no 
danger  from  the  introduction  of  instruments  into  the  vertebral 
canal,  as,  for  instance,  in  the  practice  of  lumbar  puncture,  of  in- 
flicting injury  upon  the  spinal  cord,  if  this  be  undertaken  below 
the  second  lumbar  vertebra.  Of  the  several  segments  of  the  spinal 
cord,  the  cervical  portion  is  included  between  the  first  cervical  and 
the  second  dorsal  vertebra,  and  attains  its  greatest  size  at  the  level 
of  the  fifth  and  sixth  cervical  vertebrse.  The  dorsal  cord  is  in- 
cluded between  the  second  and  the  tenth  dorsal  vertebra,  and  the 
lumbar  cord  between  the  tenth  dorsal  and  the  second  lumbar 
vertebra,  its  greatest  size  corresponding  with  the  level  of  the 
twelfth  dorsal  vertebra. 

In  order  to  form  a  proper  conception  of  the  vertebral  column  it 
should  be  recalled  that  the  spinous  process  of  the  seventh  cervical 
vertebra  projects  markedly  backward,  whence  the  name  vertebra 
prominens,  and  for  which  reason  it  can  be  readily  recognized.  If 
three  contiguous  spinous  processes  project  conspicuously  backward, 
the  middle  one  may  be  considered  as  belonging  to  the  seventh 
cervical.  It  is  accordingly  easy  to  localize  accurately  visible  or 
palpable  alterations  in  the  vertel^ral  column.  Should,  however,  such 
external  indications  be  absent,  it  will  be  necessary,  in  order  to  deter- 
mine the  level  of  disease  in  the  spinal  cord,  to  observe  whether,  on 
percussion  of  the  vertebral  column  or  on  passing  over  it  a  sponge 
wrung  out  of  hot  water  or  by  means  of  the  kathode  of  a  galvanic 
current,  a  circumscribed  point  of  pain  can  be  demonstrated ;  or, 
if  cutaneous  anesthesia  be  present,  an  attempt  should  be  made 
to  fix  its  upper  limit  at  the  side  of  the  vertebral  coliunn.  In  the 
latter  event,  naturally,  it  should  be  borne  in  mind  that  the  indi- 
vidual nerve-roots  pursue  a  longer  course  in  tiie  vertebral  canal, 
before  they  reach  the  intervertebral  foramina  and  make  their  exit, 
the  lower  the  level  at  wliich  they  leave  the  spinal  cord.  There- 
fore, the  upper  limit  of  the  anesthetic  cutaneous  area  will  approxi- 


DISEASES  OF  THE  SPINAL   COED  541 

mately  correspond  with  the  level  of  the  focus  of  disease  only  when 
this  is  situated  in  the  upper  portion  of  the  spinal  cord.  The  area 
of  cutaneous  anesthesia  at  the  side  of  the  spinal  column  will  occupy 
a  lower  level  than  the  seat  of  the  disease  if  this  be  situated  in  the 
lower  portion  of  the  spinal  cord.  In  general,  the  following  rules 
will  be  found  to  hold  good  : 

Foei  of  disease  below  the  twelfth  dorsal  vertebra  {lower  lumbar 
cord)  are  attended  with  anesthesia  in  the  lower  extremities,  except 
upon  the  outer  and  inner  aspects  of  the  thighs  and  the  inner 
aspect  of  the  legs  (external  cutaneous  nerve  of  the  thigh,  obturator, 
crural,  and  saphenous  nerves). 

Foci  of  disease  betiveen  the  tenth  and  the  eleventh  dorsal  vertebra 
{tipper  lumbar  cord)  are  attended  with  anesthesia  of  the  whole  of 
the  lower  extremities. 

In  the  presence  of  foci  of  disease  at  the  level  of  the  eighth  dorsal 
vei'tebra  {point  of  exit  for  the  terdh  dorsal  nerve)  the  anesthesia 
extends  to  the  level  of  the  umbilicus. 

Foci  of  disease  between  the  fifth  and  the  seventh  dorsal  vertebra 
{points  of  exit  for  the  sixth  and  seventh  dorsal  nerves)  give  rise  to 
anesthesia  at  the  level  of  the  ensiform  cartilage. 

Foci  of  disease  at  the  level  of  the  first  dorsal  vertebra  give  rise  to 
anesthesia  to  the  level  of  the  nipples. 

Foci  of  disease  betiveen  the  fourth  and  the  fifth  cervical  vertebra 
give  rise  to  anesthesia  to  the  level  of  the  clavicles. 

Foci  of  disease  at  the  level  of  the  upper  cervical  vertebrce  give 
rise  to  anesthesia  in  the  arms. 

For  the  comprehension  of  certain  diseases  of  the  spinal  cord  it 
is  important  to  know  that  the  relation  between  the  dura  mater  and 
the  spinal  column  differs  from  that  between  the  dura  mater  and  the 
bones  of  the  skull,  as  in  the  cranium  the  dura  is  closely  applied  to 
the  inner  surface  of  the  bones,  while  in  the  spinal  canal  it  is 
separated  from  the  inner  surface  of  the  vertebrae  by  loose  con- 
nective tissue  containing  considerable  fat  and  numerous  veins.  It 
therefore  not  rarely  happens  that  foci  of  disease  develop  in  the 
vertebral  canal  that  may  involve  the  spinal  cord  in  coiLsequence 
of  pressure  or  by  extension  of  inflammatory  processes. 

In  transverse  sections  of  the  spinal  cord  two  varieties  of  tissue 
may  be  distinguished  by  differences  in  color,  an  outer  or  white  sub- 
stance and  an  inner  or  g)ru/  substance.  The  white  matter  of  the 
spinal  cord  consists  principally  of  medullated  nerve-fibers,  and  is 
rather  a  conducting  organ,  while  the  gray  matter  contains  numer- 
ous ganglion-cells,  and  may  be  considered  the  seat  of  a  series  of 
spinal  centers.  In  each  half  of  the  spinal  cord  an  anterior  and 
a  posterior  horn  can  be  distinguished  in  the  gray  matter.  The 
two  sides  of  the  gray  matter  are  connected  by  means  of  the  gray 
commissure.  The  shape  of  the  gray  matter  of  the  spinal  cord  has 
not  inappropriately  been  compared  with  the  letter  H,  although  it 


542 


NERVOUS  SYSTEM 


2 


Vk 


will  be  readily  discerned  that  the  shape  of  the  H  varies  in  the  dif- 
ferent segments  of  the  cord.  It  is  well  to  train  the  eye  to  recog- 
nize from  the  shape  of  the  gray  matter  the  segment  of  the  cord  to 
which  it  belongs.  In  the  lumbar  segment  the  anterior  and  pos- 
terior horns  are  club-shaped  (Fig.  75,  5,  6,  7),  while  in  the  dorsal 
region  both  horns  are  exceedingly  small  (Fig. 
75,  4),  and  in  the  cervical  portion  the  anterior 
horn  particularly  assumes  a  serrated  appearance 
(Fig.  75,1,  2,3).  _ 

Both  in  the  white  and  in  the  gray  matter  of 
the  spinal  cord  definite,  associated  groups  of 
nerve-fibers  or  of  ganglion-cells  can  be  distin- 
guished, and  these  have  been  designated  also 
systems  of  the  spinal  cord.  They  have  been  dis- 
covered in  part  by  developmental  methods,  in 
part  by  experimental  means,  and  from  a  study 
of  diseases  of  the  spinal  cord. 

In  the  anterior  horns  of  the  spinal  cord  the 
large  multipolar  ganglion-cells,  which  are  gener- 
ally arranged  in  three  groups  close  together,  form 
a  connected  system.  Among  their  processes  the 
axis-cylinder  process  in  particular  is  of  great 
importance,  for  soon  after  leaving  the  ganglion- 
cell  it  becomes  surrounded  by  a  medullary 
sheath  and  enters  the  anterior  nerve-root  of  the 
spinal  cord,  then  the  peripheral  motor  nerve- 
trunk,  and  finally  the  related  muscle-fiber.  Ac- 
cordingly, ganglion-cell,  axis-cylinder  process, 
peripheral  nerve-fiber,  and  muscle  constitute  a 
continuous  and  uninterrupted  whole,  which  has 
been  designated  a  neuron,  or,  more  accurately, 
a  spinal-peripheral  neuron  or  a  neuron  of  the 
first  degree. 

Disease  of  the  ganglion-cells  of  the  anterior 
horns  is  knoM'n  also  as  anterior  poliornyelitis 
(7ro?M^,  gray).  The  characteristics  of  such 
disease  are  relaxed  (flaccid)  paralysis  of  the 
cofd°"natura^'^size^'^i^  related  musclcs,  rapid  degenerative  muscular 
I'omniencement,  2,  mid-  atrophv,  degenerative   electric   reaction  in  the 

die,  and  3,  termination  it  ^  i  i     t^'  !>  xi 

paralyzed  nerves  and  muscles,  abolition  oi  the 
reflexes,  preservation  of  cutaneous  sensibility  and 
of  the  muscular  power  of  the  bladder  and  the 
rectum.  The  ganglion-cells  in  question  possess 
trophic-motor  functions.  If  they  are  destroyed, 
the  related  axis-cylinder  processes  undergo  de- 
generation, which  extends  to  the  muscle-fibers.  Degenerated 
nerves  and  muscles  yield  degenerative  electric  reaction.     These 


Fig.  75. — Transverse 


of  the  cervical  enlarge 
nient ;  4,  middle  of  the 
dorsal  cord ;  5,  com- 
mencement, 6,  middle, 
and  7,  termination  of 
the  lumbar  enlarge- 
ment (from  personal 
preparations). 


DISEASES  OF  THE  SPINAL  CORD  543 

ganglion-cells  do  not  possess  sensory  functions.  The  reflexes  are 
abolished  in  the  region  controlled  by  the  area  of  disease,  because 
the  transference  of  sensory  stimuli  to  the  motor  paths  within  the 
spinal  cord  has  been  rendered  impossible  in  consequence  of  the 
disease  of  the  ganglion-cells. 

In  the  gray  matter  of  the  dorsal  portion  of  the  spinal  cord  at  the  junc- 
tion between  the  anterior  and  posterior  horns  there  is  an  associated  group 
of  ganglion-cells  bearing  the  name  of  the  column  of  Clarke  or  the  vesicular 
column.  It  is  known  that  the  fibers  for  the  lateral  cerebellar  tract  of  the 
spinal  cord,  shortly  to  be  mentioned,  have  their  origin  here,  but  nothing  is 
known  definitely  with  regard  to  their  function. 

The  following  columns  or  fiber-systems  may  be  distinguished 
in  the  white  substance  of  the  spinal  cojxl  on  either  side : 

1.  The  direct  or  anterior  pyramidal  tract, 

2.  The  crossed  or  lateral  pyramidal  tract, 

3.  The  lateral  cerebellar  tract, 

4.  Gowers'  column  or  the  antero-lateral  fasciculus, 

5.  The  postero-exterual  or  Burdach's  column, 

6.  The  postero-internal  or  GolFs  column, 

7.  The  antero-lateral  remnant. 

The  crossed  or  lateral  pyramidal  tracts  are  situated  in  the  lateral 
columns  of  the  spinal  cord,  and  are  separated  from  the  periphery 
of  the  cord  in  tfie  cervical  and  dorsal  regions  by  the  lateral  cere- 
bellar tracts,  while  in  the  lumbar  region  they  reach  the  periphery 
and  at  the  same  time  assume  a  wedge-siiaped  appearance  (Fig.  76, 
2psb).  .  These  tracts  contain  the  largest  portion  of  the  motor 
fibers,  which  pass  from  the  motor  cortical  centers  in  the  anterior 
and  posterior  central  convolutions,  through  the  corona  radiata, 
the  internal  capsule,  the  cerebral  peduncle,  the  pons,  and  the 
medulla  oblongata  into  the  spinal  cord,  where  they  enter  into  re- 
lations with  the  motor-trophic  ganglion-cells  in  the  anterior  horns, 
and  from  these  conduct  voluntary  impulses  to  the  periphery  of  the 
body.  Each  individual  nerve-fiber  of  these  tracts  originates  from 
the  axis-cylinder  process  of  a  motor  pyramidal  cell,  and  continues 
without  interruption  to  the  lateral  pyramidal  tract  of  the  spinal 
cord.  Here  the  individual  nerve-fiber  passes  into  the  gray  matter 
of  the  spinal  cord  and  breaks  np  into  numerous  ramifications.  The 
latter  come  into  contact  with  the  ganglion-cells  by  means  of  sim- 
ilar ramifications  (protoplasmic  processes),  M'hich  suffice  for  the 
transmission  of  voluntary  impulses.  The  pyramidal  cell,  with  its 
axis-cylinder  process  and  the  ramification  of  the  latter  in  the  gray 
matter  of  the  spinal  cord,  is  likewise  designated  a  neuron,  and  it 
is  described  as  a  neuron  of  the  second  degree  or  a  cerebrosp>inal 
neuron.  Thus,  the  entire  motor  pyramidal  (corticorauscular) 
tract,  from  the  cerebral  cortex  to  the  muscle,  is  constituted  of  two 
neurons,  which  are  connected  within  the  anterior  horn  of  the  spinal 
cord  by  contact.     The  lateral  pyramidal  tract  is  known  also  as 


z.     'i'P 


7  vsr 


Level  of  the  first 
cervical  nerve 


r2psh 
^        4     6,-/,S      ^^^'S 


Third  cervical  nerve 


■  Sixth  cervical  nerve  — i 


Third  dorsal  nerve I 


Sixth  dorsal  nerve 


Twelfth  dorsal  nerve 


Fourth  Ittmbar  nerve  — 


»«,  Fig.  <6.— Diagrammatic  representation  of  tlu  irin,  ijal  columns  of  the  spinal  cord  • 
Ipvs,  anterior  pyramidal  tracts  (direct);  2;).sh.  lateral  pyramidal  tracts  (crossed)  Ssi-ft  lat- 
eral cerebellar  tracts:  Unk,,  postero-external  (Bnrdnch'si  wodee^aped  column  '5i!-» 
postero-internal  (Goll's)  column  ;  6,  Gowers'  column  :  7,;r.  anterolateral  remnant  divid- 
cofum    •  &r!?"nd-bundles  of  the  anterior  column  and  the  remnant  of  the  lateral 

544 


DISEASES  OF  THE  SPINAL   CORD  545 

the  crossed  pyramidal  tract  because  the  motor  fibers  from  the  cere- 
bral hemisphere  upon  one  side  largely  pass  over  within  the  pyra- 
midal decussation  in  the  medulla  oblongata  to  the  lateral  pyra- 
midal tract  of  the  opposite  half  of  the  spinal  cord.  From  what  has 
been  said,  it  will  therefore  be  understood  that  destruction  of  the 
pyramidal  tract  at  any  point  in  its  course  must  be  followed  by 
motor  paralysis.  Should  the  disease  be  situated  above  the  pyra- 
midal decussation  the  paralysis  will  occur  upon  the  opposite  side 
of  the  body ;  but  if,  on  the  other  hand,  the  disease  is  situated 
below  the  decussation,  thus  in  the  spinal  cord  itself,  the  paralysis 
will  occur  upon  the  same  side.  In  contradistinction  from  paral- 
ysis resulting  from  anterior  poliomyelitis,  evidences  of  degenerative 
muscular  atrophy  and  degenerative  electric  reaction  are  wanting 
in  the  paralyzed  members;  besides,  the  reflexes  are  preserved, 
because  degeneration  of  the  peripheral  nerves  and  muscles  and 
interruption  of  the  spinal  reflex  arc  do  not  occur,  while,  on  the 
other  hand,  a  tendency  to  spasm  and  muscular  contracture  is 
present,  with  exaggeration  of  the  tendon-reflexes. 

The  direct  or  anterior  pi/ramidcd  tract  is  situated  in  the  anterior 
column  of  the  cord,' just  beside  the  anterior  longitudinal  fissure 
(Fig.  76,  Ipvs).  It  is  of  subordinate  importance  and  at  times  is 
wholly  wanting.  It  is  known  as  the  direct  pyramidal  tract  because 
it  contains  those  portions  of  one  corticomuscular  pyramidal  tract 
that  do  not  cross  over  in  the  pyramidal  decussation  to  the  lateral 
pyramidal  tract  of  the  opposite  half  of  the  cord,  but  remain  upon 
the  same  side,  in  order  to  enter  the  anterior  pyramidal  tract,  and 
only  within  the  spinal  cord  to  pass  over  to  the  other  side  of  the 
cord  through  the  intermediation  of  the  anterior  spinal  commissure. 

Various  differences  occur  in  the  relation  between  the  anterior  and  the 
lateral  pyramidal  tracts.  At  times  the  anterior  pyramidal  tract  is  wholly 
wanting,  or,  as  occurs  less  commonly,  it  preponderates  over  the  lateral 
pyramidal  tract. 

The  lateral  cerebellar  tract  (Fig.  76,  Sksb)  is  situated  in  the 
lateral  columns  of  the  cord  close  to  the  periphery,  while  inter- 
nally it  adjoins  the  lateral  pyramidal  tract.  As  has  been  men- 
tioned, its  fibers  originate  from  the  ganglion-cells  of  the  columns 
of  Clarke,  and  as  the  latter  are  present  only  in  the  dorsal  cord,  it 
will  be  understood  that  the  lumbar  cord  contains  no  lateral  cere- 
bellar tract.  The  lateral  cerebellar  tract  can  be  followed  upward 
into  the  restiform  body  of  the  medulla  oblongata,  and  thence  into 
the  superior  vermiform  process  of  the  cerebellum.  Coordinative 
functions  are  attributed  to  this  tract,  although  this  is  based  upon 
conjecture  rather  than  upon  fact. 

A  small  portion  of  the  white  substance  of  the  spinal  cord  sit- 
uated posteriorly  in  the  angle  between  the  lateral  cerebellar  and 
the  lateral  pyramidal  tract,  and  extending  forward  along  tlie 
periphery  of  the  cord  as  a  narrow  band  to  the  neighborhood  of  the 

35 


546  NERVOUS  SYSTEM 

anterior  longitudinal  fissure,  is  known  as  the  column  of  Gowers  or 
the  anterolaleral  fasciculus.  Gowers  believes  this  tract  to  conduct 
centripetally. 

The  columns  of  Bur  da  ch  and  of  Goll  in  the  posterior  columns 
of  the  spinal  cord  are  separated  with  particular  distinctness  in  the 
cervical  cord  by  a  depression  (posterior  intermediate  fissure).  The 
columns  of  Goll  contain  fibers  from  the  posterior  spinal  nerve- 
roots.  The  nerve-fibers  that  enter  at  the  lowermost  level  are  dis- 
placed progressively  further  forward  and  inward  by  those  that 
enter  at  higher  levels.  Above,  the  fibers  terminate  in  the  nucleus 
funiculi  gracilis,  and  they  pass  from  here  to  the  tegmentum,  the 
quadrigeminate  bodies,  and  the  optic  thalami.  The  nerve-fibers 
of  the  columns  of  Burdach  reach  the  nucleus  funiculi  cuneati  and 
the  olive  at  the  same  level  as  the  nucleus  funiculi  gracilis.  As  a 
unilateral  lesion  of  the  spinal  cord  gives  rise  to  anesthesia  upon 
the  opposite  side  of  the  body,  it  must  be  concluded  that  the  spinal 
sensory  paths  undergo  decussation  Avithin  the  cord.  This  takes 
place  in  the  posterior  aud  perhaps  also  in  the  anterior  spinal  com- 
missure. 

The  anterolateral  remnant  includes  those  nerve-fibers  that  are 
situated  in  the  anterior  and  lateral  columns  of  the  spinal  cord  and 
do  not  belong  to  the  pyramidal  tracts,  the  lateral  cerebellar  tracts, 
and  Gowers'  tract  (Fig.  76,  Irsi-).  They  are  considered  to  be  short 
spinal  paths  whose  function  consists  in  connecting  the  ganglion- 
cells  in  the  gray  matter  of  the  spinal  cord  with  one  another. 

Disease  of  the  spinal  cord  is  revealed  by  disturbances  in  the 
function  of  the  cord.  The  nature  of  these  disturbances  will  de- 
pend upon  the  seat  of  the  disease.  iSIotor,  sensory,  vasomotor, 
secretory,  trophic,  and  reflex  disturbances  may  be  present. 

Spinal  paralysis  indicates  disease  either  of^  the  large  ganglion- 
cells  in  the  anterior  horns  of  the  spinal  cord,  or  of  the  lateral 
pvramidal  tracts.  In  each  instance  the  character  of  the  paralysis 
is  different,  as  has  been  mentioned  on  pp.  542,  545. 

Sensory  disturbances  will  be  present  when  the  posterior  columns 
of  the  cord  or  the  posterior  horns  are  diseased.  It  is  believed 
that  the  fibers  for  painful  and  thermal  sensibility  pass  through  the 
horns,  while  the  fibers  for  tactile  sensibility  pass  through  the  pos- 
terior columns. 

Vasomotor  disturbances  are  not  uncommonly  associated  with 
disease  of  the  spinal  cord.  The  vasomotor  nerve-paths  are  be- 
lieved to  pa.ss  from  the  brain  to  the  lateral  column  of  the  spinal 
cord,  then  to  enter  the  anterior  horn,  and  to  extend  from  this 
through  the  anterior  nerve-roots  to  the  periphery  of  the  body. 
In  addition,  there  are  spinal  vasomotor  centers,  which  are  capable 
of  acting  independently  of  the  brain,  but  nothing  definite  is  known 
with  regard  to  their  situation. 

Trophic  disturbances  occur,  as  has  been  mentioned,  in  muscles, 


ANEMIA   OF  THE  SPINAL  CORD  547 

fascia,  bones,  and  joints  in  connection  with  anterior  poliomyelitis. 
The  posterior  horns  of  the  spinal  cord  also  are  credited  with 
trophic  functions,  as  trophic,  that  is,  acute,  gangrene  of  the  skin, 
independent  of  pressure  and  infection,  has  been  observed  in  con- 
nection with  posterior  poliomyelitis. 

Alterations  in  the  reflexes  are  manifested  at  times  in  exaggera- 
tion, at  other  times  in  abolition  of  reflex  movement.  The  former 
occurs,  for  instance,  in  association  with  spastic  spinal  paralysis ; 
the  latter  in  association  with  tabes  dorsalis.  The  spinal  cord  is 
necessary  for  the  occurrence  of  the  reflexes,  because  the  transfer- 
ence of  reflex  irritation  from  the  sensory  to  the  motor  paths  takes 
place  within  the  gray  matter  of  the  cord.  Every  interruption  of 
the  reflex  arc  will  be  attended  with  abolition  of  reflex  movement, 
and  this  may  naturally  result  from  disease  of  the  sensory  or  of 
the  motor  path  or  of  the  spinal  cord.  Exaggeration  of  reflex 
movement  is  often  attributed  to  the  withdrawal  of  the  inhibitory 
activity  of  nerve-flbers  entering  the  spinal  cord  from  the  brain. 

The  diseases  of  the  spinal  cord  may  be  divided  into  two  natural 
groups,  namely  :  the  diseases  of  the  structwe  of  the  cord  and  those 
of  the  spinal  membranes.  The  diseases  of  the  spinal  cord  proper 
may  be  in  turn  irregular  in  distribution — atypical  or  asystematic 
diseases  of  the  spinal  cord  ;  or  they  may  remain  confined  to  definite 
systems — typiccd  or  systematic  diseases  of  the  spinal  cord.  In  the 
latter  event  a  single  system  or  several  systems  may  be  involved, 
and  a  distinction  is  accordingly  made  between  single  and  combined 
system-diseases  of  the  sjnnal  cord.  Diseases  of  the  spinal  cord  in 
which  it  has  not  yet  been  possible  to  discover  anatomic  alterations 
are  designated /?mcf?07ia^  diseases  of  the  spinal  cord,  or  neuroses  of 
the  spinal  cord. 

DISEASES  OF  THE  SPINAL   CORD. 

Atypical  or  Asystematic  Diseases  of  the  Spinal  Cord. 

ANEMIA  OF  THE  SPINAL  CORD. 

The  condition  of  anemia  of  the  spinal  cord  is  without  clinical 
significance.  Naturally,  it  will  appear  in  the  course  of  general 
anemia,  such  as  may  occur  in  consequence  of  excessive  hemorrhage, 
in  association  with  certain  diseases  of  the  blood  (chlorosis,  leukemia, 
pseudoleukemia,  pernicious  anemia),  and  following  debilitating 
diseases  (carcinoma,  pulmonary  tuberculosis,  suppuration,  chronic 
diarrhea).  Such  patients  not  rarely  complain  of  spinal  symptoms, 
such  as  paresthesia,  hyperesthesia,  or  anesthesia,  tremor,  undue 
readiness  of  fatigue,  and  the  like,  symptoms  that  have  been  at- 
tributed to  anemia  of  the  spinal  cord.  Spinal  anemia  due  to  more 
especially  local  causes  has  been  observed  in  connection  with  embo- 


548  NERVOUS  SYSTEM 

limi  and  thrombosis  of  the  abdominal  aorta.  Under  such  circum- 
stances there  develop,  in  consequence  of  anemia  of  the  hinibar 
cord,  paraplegia  and  anesthesia  in  the  lower  extremities,  paralysis 
of  the  bladder  and  the  rectum,  and  abolition  of  reflex  movement 
and  electric  irritability.  Absence  of  pulsation  in  the  femoral 
artery  is  distinctive  of  this  condition.  In  consequence  of  an  in- 
adequate supply  of  blood  giingrene  of  the  lower  extremities  soon 
develops,  and  death  occurs  as  the  result  of  septicemia.  In  all 
cases  of  anemia  of  the  spinal  cord  the  treatment  will  consist 
principally  in  relief  of  the  primary  disorder. 

HYPEREMIA  OF  THE  SPINAL  CORD. 

Hyperemia  of  the  spinal  cord  may  result  from  increased  arterial 
supply  or  obstructed  venous  exit,  and  a  distinction  is  accordingly 
made  between  arterial  and  venous  hyperemia  of  the  spinal  cord. 
Little  of  a  definite  nature  is  known  concerning  both  conditions, 
and  they  are  therefore  as  yet  of  no  clinical  significance. 

Arterial  hyperemia  of  the  spinal  cord  may  develop  as  a  result 
of  traumatism,  infectious  diseases,  sexual  excesses,  and  certain  in- 
toxications (alcohol,  amyl  nitrite)  ;  while  venous  hyperemia  oj  the 
spinal  cord  develops  in  conjunction  with  stasis  resulting  from 
chronic  disease  of  the  heart,  lungs,  or  liver,  and  convulsive  dis- 
orders (tetanus,  epilepsy,  uremia). 

Among  the  Sjntnptoms  of  hypereniia  of  the  spinal  cord  a  sense 
of  traction  in  the  sacral  region,  rigidity  of  the  spinal  column, 
girdle-sense,  drawing  and  pain  in  the  lower  extremities,  paresthesia, 
hyperesthesia,  and  anesthesia,  and  twitching  and  paralysis  of  the 
muscles  have  been  mentioned.  Xo  characteristic  symptom  is 
known,  and  generally  the  diagnosis  is  made,  in  the  presence  of 
spinal  symptoms  in  association  with  demonstrable  causes  of 
hyperemia  of  the  spinal  cord,  by  attributing  the  former  to  the 
latter. 

The  treatment  should  lie  directed  less  to  the  circulatory  dis- 
turbances in  the  spinal  cord  than  to  the  primary  disorder. 

HEMORRHAGE  INTO  THE  SPINAL  CORD. 

Htiologfy. — Hemorrhage  into  the  spinal  cord  or  hematomyelia 
includes  only  such  extravasations  of  blood  as  take  place  suddenly 
into  the  substance  of  a  healthy  spinal  cord.  Such  hemorrhage  is 
rare,  and  is  to  be  carefully  distinguished  from  the  more  common 
hemorrhage  that  takes  place  into  inflamed  and  softened  spinal 
tissue,  and  is  designated  hematomyelitis.  Hemorrhage  into  the 
spinal  cord  may  result  from  injury — traumatic  spinal  hemorrhage. 
The  causative  factors  include  not  only  concussion  and  injury  of 
the   vertebral   column,   but    also  heavy  lifting,  strong  expulsive 


HEMORRHAGE  INTO   THE  SPINAL   CORD  549 

efforts,  and  the  like.  Exposure  to  cold  is  likewise  not  without 
influence ;  at  least,  a  jwitient  under  my  cure  was  sei/x'd  with 
hemorrhage  into  the  spinal  cord  at  a  hathing- resort  as  a  cold 
douche  was  directed  against  the  vertebral  column.  Of  import- 
ance are  processes  in  the  sexual  sphere,  particularly  venereal 
excesses  and  amenorrhea.  Suppression  of  hemorrhoidal  bleeding 
also  has  been  stated  to  provoke  a  tendency  to  spinal  hemorrhage. 
Excessive  indulgence  in  alcohol  appears  to  be  not  without  influ- 
ence. Cases,  however,  occur  also  in  which  no  exciting  cause  for 
the  spinal  hemorrhage  can  be  demonstrated.  The  disorder  develops 
most  commonly  in  men  between  the  twentieth  and  the  fortieth  year 
of  life. 

Anatomic  Alterations. — Hemorrhage  into  the  spinal  cord 
may  be  classified  according  to  the  external  appearance  into 
transverse,  longitudinal,  and  circumscribed.  In  cases  of  transverse 
hemorrhage  into  the  spinal  cord  the  extravasation  involves  the 
entire  transverse  section  or  it  may  be  confined  accidentally  to 
one-half  of  the  cord — unilateral  hemorrhage.  After  incision  of 
the  dura  the  extravasation  of  blood  can  frequently  be  distinguished 
beneath  the  pia  as  a  dark,  reddish-black  collection,  which  at 
times  pushes  the  pia  outward  and  projects  above  the  level  of 
the  adjacent  healthy  spinal  tissue.  At  times  the  pia  and  even 
the  arachnoid  are  suffused  with  blood.  Blood  may  also  be  ad- 
mixed with  the  cerebrospinal  fluid,  and  impart  to  this  a  reddish, 
bloody  appearance.  On  section  through  the  hemorrhagic  focus 
the  appearances  vary  with  its  age.  In  recent  cases  it  consists  of 
a  soft  bloody  mass,  constituted  of  red  blood-corpuscles  and  dis- 
integrated spinal  tissue.  The  older  the  lesion  the  more  con- 
spicuous on  microscopic  examination  are  fatty  degeneration  and 
disorganization  of  the  injured  nerve-fibers.  There  are  present 
numerous  fatty  granule-cells,  which  are  nothing  more  than  emi- 
grated colorless  blood-corpuscles,  which  have  become  laden  with 
the  not  readily  absorbed  fat  for  the  purpose  of  hastening  its 
absorption.  Older  hemorrhagic  foci  are  appreciable  even  to  the 
unaided  eye  from  their  reddish-brown  appearance,  and  they  are 
likely  to  present  a  more  firm  consistence.  Microscopically,  in 
addition  to  fatty  granule-cells,  red  blood-corpuscles  are  found  in 
various  stages  of  disorganization.  Here  and  there  granules, 
needles,  and  plates  of  precipitat(>d  hematoidin  are  also  present. 

Gradually  a  hemorrhagic  extravasation  may  undergo  complete 
absorption,  and  there  will  remain  in  its  place  a  cavity  filled  with 
serous  fluid  whose  wall  is  constituted  by  proliferated  neuroglia — 
apoplectic  cyst.  In  addition,  secondary  degeneration  of  the  spinal 
cord  occurs  above  and  below  the  hemorrhagic  extravasation  :  above, 
ascending  degeneration  of  the  columns  of  Goll,  the  lateral  cere- 
bellar tracts  and  Gowers'  bundle ;  below,  descending  degenera- 
tion of  the  lateral  and  anterior  pyramidal  tracts.    Only  rarely  will 


550  NERVOUS  SYSTEM 

it  be  possible  on  microscopic  examination  to  find  the  rnptured 
spinal  vessel  responsible  for  the  hemorrhage.  If  the  blood-vessels 
exhibit  any  change,  this  generally  consists  in  secondary  prolifera- 
tion of  nuclei  and  in  fatty  degeneration.  Miliary  aneurysms, 
which  are  as  a  rule  responsible  for  hemorrhage  into  the  brain, 
seldom  occur  in  the  spinal  cord. 

Tubular  hemorrhage  into  the  spinal  cord  extends  especially  in 
the  longitudinal  axis  of  the  cord,  and  at  times  attains  a  length  of 
several  centimeters.  Naturally,  the  white  matter  of  the  cord 
oifers  considerably  more  resistance  to  the  extension  of  the  hemor- 
rhage than  the  grav  matter.  Circumscribed  hemorrhages  into  the 
cord  consist  of  small  extravasations  of  l)lood  tliat  involve  only 
certain  small  portions  of  the  cord.  The  gray  matter  of  the  cord 
is  more  susceptible  to  all  varieties  of  hemorrhage  on  account  of  its 
greater  abundance  of  blood-vessels,  and  it  is,  therefore,  a  rela- 
tively common  seat  of  circumscribed  spinal  hemorrhage.  Small 
extravasations  of  blood  in  the  spinal  cord  may  disappear  and  leave 
only  a  brownish  or  yellowish  cicatrix  consisting  of  neuroglia — 
apoplectic  cicatrix. 

Symptoms  and  Diagnosis. — The  sudden  occurrence  of 
spinal  symptoms  is  distinctive  of  all  varieties  of  hemorrhage  into 
the  spinal  cord.  In  other  respects  the  symptoms  vary  in  accordance 
with  the  extent  and  the  situation  of  the  extravasation.  Transverse 
hemorrhage  in  the  lumbar  or  dorsal  cord  is  attended  with  suddenly 
developed  paraplegia  in  the  lower  extremities.  At  the  same  time 
there  is  anesthesia.  The  tendon-reflexes,  particularly  the  knee-jerks, 
are  generallv  enfeebled  for  the  first  few  days,  and  this  is  thought 
to  be  due  to  the  general  concussion  of  the  spinal  cord  induced  by 
the  hemorrhage ;  subsequently  the  tendon-reflexes  become  exag- 
gerated. The  tendon-reflexes  remain  permanently  abolished  only 
when  the  hemorrhage  destroys  the  lumbar  cord  and  thereby  inter- 
rupts the  spinal  reflex  arc.  In  the  latter  event  paralysis  of  the 
bladder  and  of  the  rectum  is  present  from  the  outset,  as  the  spinal 
centers  for  the  bladder  and  the  rectum  in  the  lowermost  portion 
of  the  lumbar  cord  are  destroyed  ;  also  in  cases  of  transverse 
hemorrhage  into  the  dorsal  cord  paralysis  of  the  bladder  and  the 
rectum  appears  after  the  lapse  of  some  time.  The  detrusor  of  the 
bladder  suffers  first,  and  the  patients  are  capable  of  emptying  the 
viscus  only  incompletely  and  with  difficulty.  Subsequently  paral- 
ysis of  the  sphincter  of  the  bladder  is  superadded,  and  the  reten- 
tion of  urine  at  first  present  is  succeeded  by  incontinence.  Bacteria 
from  the  air  and  the  urethra  readily  gain  entrance  into  the  bladder, 
and  cause  fermentation  of  the  urine  and  readily  excite  cystitis, 
pyelonephritis,  and  urinary  septicemia.  Incontinence  of  urine  also 
is  attended  with  the  danger  of  cutaneous  irritation,  of  bed-sores, 
and  of  septicemia.  In  cases  of  transverse  hemorrhage  in  the  upper 
portion  of  the  spinal  cord  symptoms  of  paraplegia  of  the  arms 


HEMORRHAGE  INTO   THE  SPINAL  CORD  551 

occur  in  addition' to  the  symptoms  described.  Heniorrha<^c  hij^li 
up  may  even  give  rise  to  bulbar  symptoms  if  the  nuclei  of  the 
cerebral  nerves  on  the  floor  of  the  fourth  ventricle  or  the  intra- 
medullary nerve-roots  of  individual  cerebral  nerves  are  involved 
in  the  morbid  process. 

With  the  occurrence  of  hemorrhage  into  the  spinal  cord  the 
patients  frequently  complain  of  severe  pain  in  the  spinal  column, 
which  is  probably  dependent  upon  sudden  distention  of  the  pia 
mater  by  the  extravasated  blood.  The  bodily  temperature  remains 
unchanged,  although  at  times  slight  elevation  of  temperature  takes 
place  in  from  three  to  five  days,  and  this  has  been  designated  reac- 
tionary fever,  and  has  been  considered  the  sequel  of  an  inflammatory 
reaction  on  the  part  of  the  spinal  tissues  surrounding  the  extrava- 
sation. If  the  transverse  section  of  the  spinal  cord  is  wholly 
destroyed  by  the  hemorrhage,  recovery  or  even  improvement 
cannot  be  anticipated,  as  regeneration  of  spinal  tissue  does  not 
take  place.  Improvement  can  be  hoped  for  only  when  part  of  the 
symptoms  result  from  pressure  exerted  by  the  extravasated  blood, 
and  this  pressure  ceases  after  absorption  of  the  blood  has  taken 
place. 

After  transverse  hemorrhage  into  the  spinal  cord  has  existed  for 
some  time  mitscidar  contractures  and  exaggeration  of  the  tendon- 
reflexes  gradually  develop  in  the  paralyzed  extremities,  conditions 
that  are  commonly  attributed  to  secondary  degeneration  of  the 
lateral  pyramidal  tracts,  although  this  has  scarcely  been  demon- 
strated with  any  degree  of  certainty.  The  principal  dangers  from 
the  disorder  are  bed-sores  and  septicemia  and  urinary  decomposi- 
tion, cystitis,  pyelonephritis,  and  urinary  septicemia. 

Unilateral  hemorrhage  into  the  spinal  cord  sets  in  suddenly  with 
the  symptoms  of  a  unilateral  lesion  of  the  spinal  cord.  Accordingly, 
paralysis  is  found  upon  the  side  of  the  hemorrhage  and  anesthesia 
upon  the  opposite  side. 

Circumscribed  hemorrhage  into  the  anterior  horns  of  the  spinal 
cord  is  attended  with  symptoms  of  anterior  poliomyelitis  (flaccid 
paralysis,  degenerative  muscular  atro])hy,  degenerative  electric 
reaction,  abolition  of  the  reflexes) ;  and  into  the  posterior  horns, 
with  partial  anesthesia,  particularly  with  loss  of  painful  and  of 
thermal  sense. 

Prognosis. — The  prognosis  of  hemorrhage  into  the  spinal 
cord  is  unfavorable,  because  such  destruction  of  the  cord  as  is 
effected  is  permanent.  At  times  gliosis  is  .said  to  have  devel- 
oped in  tlic  sequence  of  spinal  hemorrhage. 

Treatment. — For  the  control  of  hemorrhage  into  the  spinal 
cord  and  to  avert  reactionary  inflammation  in  the  spinal  tissue  an 
ice-bag  should  be  applied  to  the  vertebral  column  at  the  site 
of  hemorrhage.  Success  can  scarcely  be  expected  from  the  inter- 
nal administration  of  hemostatics.     To  hasten  absorption  of  the 


552  NERVOUS  SYSTEM 

.blood,  sorbefacicnts,  particularly  potas.siimi  iodic!  (5.0  :  200 — 75 
grains  :  G^  liuidouuces  ;  15  c.o. — 1  tablespoontul — thrice  daily), 
are  often  prescribed,  but  it  is  at  least  doul)tful  whether  they 
have  any  effect.  If  symptoms  of  paralysis  of  the  bladder 
and  tiio  rectum  appear,  attempts  should  be  made  in  the  pres- 
ence of  retention  of  urine  to  secure  evacuation  of  the  bladder 
thrice  daily  l\v  means  of  compression  of  the  bladder  through  the 
abdominal  -wall.  The  catheter  should  be  resorted  to  only  when 
the  procedure  mentioned  proves  unsuccessful,  and  in  that  event 
most  rigid  disinfection  of  the  catheter  must  be  secured.  If  incon- 
tinence of  urine  has  developed,  the  urine  should  be  collected  in 
a  suitable  receptacle.  The  skin  of  the  buttocks  and  the  vicinity 
should  be  thoroughly  cleansed  morning  and  evening  of  all  con- 
tamination, and  -washed  with  alcohol  in  order  to  avert  bed-sores. 
It  is,  further,  important  to  change  the  posture  of  the  body  several 
times  during  the  day.  If,  in  spite  of  these  precautions,  redness 
and  discoloration  of  the  skin  appear,  the  surface  should  be  covered 
with  smoothly  applied  adhesive  plaster,  and  the  patient  should  be 
placed  upon  a  hair  mattress  or  a  water-bed.  If  a  bed-sore 
be  present  when  the  patient  comes  under  observation,  it  should 
be  covered  with  cotton  that  has  been  immersed  in  camphorated 
wine,  or  the  patient  should  be  placed  permanentlv  in  a  M'arm  bath 
at  a  temperature  of  28°  R.  (35°  C\— 95°  F.).  Xot  much  will  be 
accomplished  Avith  electric  treatment  of  the  spinal  lesion  and  the 
paralvzed  muscles.  Massage  of  the  paralyzed  muscles  should 
preferably  be  recommended  in  order  to  maintain  the  nutrition  of 
the  muscles  and  to  avert  the  development  of  contractures. 


ACUTE  INFLAMMATION  OF  THE  SPINAL  CORD 
(ACUTE  MYELITIS;. 

Htiology. — Acute  inflammation  of  the  s])inal  cord  probably 
develops  generally  as  a  result  of  the  activity  of  bacteria,  and 
those  influences  that  have  hitherto  been  considered  as  the  causes 
of  the  disease  are  probably  without  other  significance  than  that  of 
contributory  agencies  for  the  infection.  Among  these  belong  par- 
ticularly exposure  to  cold,  traHinatism,  and  jweceding  infectious  dis- 
ease. Also,  states  of  hy])eremia  of  the  spinal  cord  appear  to  favor 
infection  of  the  cord.  In  women  sym]>toms  of  spinal  inflamma- 
tion appear  at  times  at  the  menstrual  period,  particularly  if  men- 
struation be  a])sent  or  delayed.  ^lyelitis  is  even  reported  to  have 
been  observed  after  profound  emotional  disturbance ;  for  instance, 
after  severe  fright. 

Inflammation  of  the  spinal  cord  may  arise  by  extension  from 
disease  of  the  verteljral  column  (carcinoma,  tuberculosis).  Acute 
neuritis  also  extends  at  times  to  the  spinal  cord.     Acute  myelitis 


ACUTE  lyFLAMMATIOX  OF  THE  SPINAL   CORD         553 

is  a  rather  uncommon  disease,  which  attacks  men  somewhat  more 

frequently  tlian  women,  and  which  occurs  particularly  in  adults. 

Anatomic  Alterations. — An  acutely  inflamed  spinal  cord 
is  characterized  In'  remarkable  softness,  so  that  the  condition 
may  be  spoken  of  as  injiammatory  spinal  softening  or  injiaMinatory 
myelomalacia.  It  should  naturally  be  remembered  that  precisely 
the  same  alterations  may  take  place  if  the  circulation  and  nutri- 
tion of  the  spinal  cord  are  cut  off  as  a  result  of  embolism  or 
thrombosis  of  Ijlood-vessels.  There  then  occurs  necrotic  spinal 
softening  or  necrotic  myelomalacia,  although  little  of  a  definite 
nature  is  known  with  regard  to  this.  In  accordance  with  the 
duration  of  the  disease  the  softened  spinal  cord  presents  a  varying 
color,  and  accordingly  a  distinction  has  been  made  between  red, 
yellow,  and  gray  softening  of  the  spinal  cord.  In  the  presence  of 
red  softening  the  color  of  the  cord  is  due  to  the  fulness  of  the 
vessels  with  blood  and  diapedesis  of  red  blood-corpuscles.  When 
numerous  extravasations  of  blood  occur  the  condition  has  been 
designated  hematornyelitis  or  hemorrhagic  myelitis.  Destruction 
of  migrated  red  blood-corpuscles,  transformation  of  their  hemo- 
globin, and  progressive  fatty  degeneration  of  the  nervous  elements 
gradually  give  rise  to  the  appearances  of  yellow  softening  of  the 
spinal  cord,  Avhich  when  the  hemoglobin  is  wholly  absorbed  is 
succeeded  by  gray  softening.  The  degree  of  softening  is  most 
variable.  In  some  cases  the  inflamed  spinal  tissue  presents  an 
almost  fluid  consistence.  At  the  same  time  it  may  happen  that 
smaller  foci  of  inflammation  are  gradually  absorbed,  and  in  their 
place  a  spinal  cyst  filled  with  serous  fluid  remains.  Should  the 
disease  pursue  a  chronic  course,  induration  or  sclerosis  of  the 
previously  softened  tissue  at  times  takes  place.  Rarely,  cases  of 
acute  myelitis  occur  in  which  accumulations  of  pus  take  place  in 
the  spinal  cord — abscess  of  the  spinal  cord,  purulent  myelitis. 

On  microscopic  examination  of  softened  spinal  tissue,  fatty  granule-cells, 
degenerated  nerve-fibers  and  ganglion-cells,  red  blood-corpuscles,  emigrated 
colorless  red  blood-corpuscles,  swelling  and  proliferation  of  glia-cells  and 
altered  blood-vessels  are  found  in  abundance.  The  vessels  exhibit  disten- 
tion with  blood,  thickening  of  their  walls,  multiplication  and  fatty  degen- 
eration of  their  nuclei,  and  often  also  the  presence  of  round  cells  and  fatty 
granule-cells  in  considerable  number  in  the  adventitial  lymph-sheaths. 
Often  the  blood-vessels  are  surrounded  by  a  collection  of  colorless  blood- 
corpuscles.  The  nerve-fibers  exhibit  disintegration,  fiitty  degeneration, 
and  atrophy  of  medullary  sheaths.  Their  axis-cylinders  often  |)resent 
marked  swelling  and  enlargement,  which  may  be  seen  with  especial  dis- 
tinctness upon  transverse  section  of  the  hardened  spinal  cord,  and  often 
increase  and  diminution  in  size  occur  alternately  in  garland-like  arrange- 
ment. Finally,  disintegration  and  disapi)earance  of  the  axis-cylinders 
takes  place.  The  ganglion-cells  become  swollen,  not  rarely  present  vacu- 
oles, lose  their  processes,  and  eventually  contract  to  small,  roundish  struc- 
tures, not  rarely  stained  deeply  brown.  If  the  inflammation  has  existed 
for  some  time,  laminated  amyloid  bodies  also  occur. 

Acute   myelitis  most  commonly  involves  the  gray  substance 


654  NERVOUS  SYSTEM 

of  the  cord,  perhaps  because  the  large  number  of  blood-vessels  in 
this  situation  readily  permits  the  entrance  of  numerous  bacteria. 
Siiould  the  inflammation  be  confined  to  the  gray  matter  of  the 
spinal  cord,  the  condition  is  spoken  of  as  central  myelitis  or  polio- 
myelitis. It  is  naturally  the  rule  for  the  inflammatory  process  to 
extend  from  the  gray  to  the  white  matter  of  the  cord.  Observa- 
tions of  inflammation  of  the  white  substance  of  the  cord  exclu- 
sively are  rare,  and  are  known  as  leukomyelitis.  Should  the  in- 
flammatory process  involve  especially  the  peripheral  layers,  the 
disease  is  designated  perimyelitis.  With  this  condition  inflamma- 
tion of  the  spinal  meninges  is  frequently  associated — acute  myelo- 
meningitis. The  distribution  of  acute  myelitis  is  extremely  variable. 
At  times  it  takes  place  principally  throughout  a  transverse  extent, 
so  that  the  entire  transverse  section  of  the  cord  is  involved  in  the 
inflammatory  focus — transverse  myelitis.  An  especial  form  of 
transverse  myelitis  consists  in  involvement  of  one-half  of  the 
spinal  cord  only.  In  some  instances  the  inflammatory  process 
exhibits  a  tendency  rather  to  extend  longitudinally,  and  at  times 
it  involves  the  entire  length  of  the  spinal  cord — diffuse  myelitis. 
Small  myelitic  areas,  which  are  often  recognized  only  on  micro- 
scopic examination  of  the  hardened  spinal  cord,  are  known  as 
circumscribed  myelitis,  and  if  a  number  of  such  areas  are  present 
in  the  spinal  cord  separated  from  one  another  the  condition  is 
designated  disseminated  or  insular  or  multiple  myelitis.  Experi- 
ence has  shown  that  the  luml)ar  and  dorsal  portions  of  the  cord 
are  the  most  common  seats  of  inflammation. 

Symptoms  and  Diagnosis. — Acute  myelitis  not  rarely 
begins,  like  an  acute  infectious  disease,  with  a  chill,  followed  by 
fever,  with  elevation  of  temperature  to  39°  or  40°  C.  (102.2°  or 
104°  F.)  and  above.  In  some  cases  a  sense  of  drawing  in  the  back, 
a  feeling  of  stiffness  in  the  vertebral  column,  and  paresthesia  in 
the  extremities  appear  as  prodromes. 

Symptoms  of  spinal  paralysis  soon  aj^pear,  and  these  correspond 
most  frequently  with  the  clinical  picture  of  transverse  myelitis  in 
the  lumbar  or  dorsal  cord.  The  patients  complain  of  a  sense  of 
weakness  in  the  lower  extremities  and  are  compelled  to  go  to  bed, 
and  even  within  a  short  time  flaccid  paralysis  of  the  extremities 
has  developed.  Painful  jerking  or  muscular  contractions  also 
occur  from  time  to  time  in  the  paralyzed  parts.  Complaint  is 
frequently  made  of  paresthesise  in  the  paralyzed  muscles,  ]Dar- 
ticularly  the  crawling  of  ants  (formication),  sticking,  prickling, 
burning,  and  also  sensations  of  cold. 

The  anesthesia  is  always  more  marked  in  the  lower  extremi- 
ties. The  tendinous  and  cutaneous  reflexes  are  wanting  when  the 
lower  portion  of  the  lumbar  cord  is  involved  in  the  inflammatory 
process,  and  its  functional  activity  is  suppressed.  When  the  in- 
flararaatorv  foci  are  situated  at  a  hig'her  level  the  reflexes  remain 


ACUTE  INFLAMMATION  OF  THE  SPINAL  CORD         555 

unchanged  or  are  even  unduly  increased.  Disease  in  the  lower 
portion  of  the  lumbar  cord  is  from  the  first  attended  with  jjar<d- 
ysis  of  the  bladder  and  the  rectum.  Of  the  muscles  of  the  bladder, 
the  detrusor  is  paralyzed  first,  and  the  patients  are  therefore  unable 
to  evacuate  the  urine,  so  that  this  fluid  accumulates  in  the  bladder, 
and  may  distend  the  latter  to  the  level  of  the  umbilicus,  and  even 
beyond  that.  Subsequently  paralysis  of  the  sphincter  of  the  blad- 
der is  superadded,  and  the  previous  retention  of  urine  is  succeeded 
by  incontinence  with  dribbling.  Under  such  circumstances  bac- 
teria readily  gain  entrance  from  the  air  through  the  urethra  into 
the  bladder,  where  they  cause  alkaline  decomposition  of  the  urine, 
which  becomes  evident  to  the  sense  of  smell  as  a  disagreeably 
pungent  urinous  odor.  Decomposed  alkaline  urine  frequently 
gives  rise  to  cystitis,  pyelonephritis,  and  urinary  septicemia,  and 
the  last  is  often  a  cause  of  death.  In  addition,  it  is  scarcely  possi- 
ble to  avoid  wetting  and  irritation  of  the  skin  over  the  sacrum 
and  the  buttocks  with  decomposed  urine,  so  that  the  development 
of  gangrene  of  the  skin  or  of  a  bed-sore  is  favored.  This  danger 
is  further  increased  by  the  fact  that  in  the  presence  of  paralysis 
of  the  sphincter  of  the  anus  fecal  matter  also  is  voided  involun- 
tarily, and  likewise  causes  irritation  of  the  skin,  and  by  the  fact 
that  if  the  patient  lies  constantly  upon  his  back  the  weight  of  his 
body  causes  pressure  upon  the  skin  in  the  sacral  region,  with 
ischemia  and  a  marked  tendency  to  the  development  of  gangrene 
and  inflammatory  alterations  in  marked  degree.  Some  patients 
complain  of  a  constricting  or  even  a  painful  girdle-sense  about  the 
trunk,  which  is  generally  attributed  to  irritation  of  the  posterior 
spinal  nerve-roots.  Pressure  upon  and  percussion  of  the  vertebral 
column  at  times  induce  pain. 

Occasionally  vasomotor,  secretory,  and  trophic  disturbances  are 
observed.  The  paralyzed  members  appear  unusually  pale  or 
strikingly  red,  and  accordingly  feel  cool  or  warm.  Not  rarely 
excessive  secretion  of  sweat  takes  place  in  the  lower  extremities 
or  the  paralyzed  members  remain  dry  in  the  presence  of  general- 
ized sweating.  Edema  also  develops,  and  is  generally  attributable 
to  stagnation  in  the  lymphatic  circulation  in  consequence  of  defi- 
cient activity.  Among  the  trophic  disturbances  some  forms  of  bed- 
sore have  been  included,  which  develop  with  unusual  rapidity  in  situa- 
tions that  are  exposed  neither  to  pressure  nor  to  want  of  cleanliness. 

Acute  myelitis  may  exhibit  a  stationary  or  a  progressive  char- 
acter. In  the  former  event  the  symptoms  are  not  progressive, 
while  in  the  latter  they  exhibit  an  unmistakable  tendency  to  extend 
more  and  more.  Under  these  circumstances  the  condition  is 
usually  attended  with  the  alterations  of  acide  ascending  myelitis. 
The  paralysis  begins  in  the  lower  extremities,  extends  then  to  tiie 
abdominal  and  subsequently  to  the  thoracic  muscles,  in  the  course 
of  a  few  days  to  the  arms,  and  finally  also  to  the  cerebral  nerves. 


556  NERVOUS  SYSTEM 

There  occur  respiratory  disturbances,  difficulty  in  swallowing, 
acceleration  and  frequently  also  irregularity  in  the  action  of  the 
heart,  and  finally  death  from  suffocation  or  paralysis  of  the  heart. 
Paralysis  of  the  phrenic  nerve  and  the  diaphragm  also  readily 
causes  death  by  suffocation.  If  pains  be  taken  to  determine  daily 
the  upper  limit  of  cutaneous  anesthesia,  it  will  be  easily  possible 
to  follow  accurately  the  extension  of  the  inflammatory  process  in 
the  spinal  cord. 

Among  the  complications  of  acute  myelitis,  cystitis  and  urinary 
septicemia,  and  bed-sores  and  general  septicemia,  are  by  far  the  most 
common  and  the  most  serious.  Bed-sores  form  with  especial  fre- 
quency over  the  sacrum,  next  in  frequency  over  the  trochanters, 
the  malleoli,  and  the  heels.  They  often  extend  in  a  frightful 
manner  in  extent  and  depth,  and  the  sacrum  may  as  a  result  be 
destroyed  and  the  vertebral  column  opened.  Acute  myelitis  may 
terminate  fatally  within  a  few  days,  particularly  if  it  assume  a 
ra]:>idly  ascending  character ;  or  the  initial  fever  gradually  sub- 
sides, but  after  the  lapse  of  several  weeks  death  occurs  as  a  result 
of  septicemia  or  of  urinary  infection ;  or  the  disease  assumes  a 
chronic  course  and  persists  for  months  or  years.  Under  the  con- 
ditions last  named  a  portion  of  the  paralytic  phenomena  may  dis- 
appear in  so  far  as  these  are  dependent  rather  upon  compression 
than  upon  actual  destruction  of  nervous  elements.  Complete 
recovery  is  scarcely  to  be  expected.  Further,  the  disease  exhibits 
a  great  tendency  to  relapjse,  in  consequence  of  insignificant  inju- 
rious influences. 

The  diagnosis  of  acute  transverse  and  of  progressive  myelitis 
is  not  difficult.  In  contradistinction  from  hemorrhage  into  the 
spinal  cord,  importance  should  be  attached  to  the  fact  that  the 
symptoms  do  not  set  in  suddenly,  but  successively.  In  the  pres- 
ence of  acute  spinal  meningitis  irritative  symptoms  predominate, 
particularly  pain.  The  presence  of  rigidity  of  the  neck  also  is  of 
importance.  Spinal  ascending  (Landry's)  paralysis  is  unattended 
with  sensory  disturbances,  as  well  as  paralysis  of  the  bladder  and 
the  rectum.  Multiple  neuritis  is  attended  with  degenerative  mus- 
cular atrophy  and  degenerative  electric  reaction  in  the  paralyzed 
nerves  and  muscles,  while  the  bladder  and  the  rectum  usually 
remain  unaffected.  From  the  clinical  course  described  such  cases 
of  acute  myelitis  will  naturally  deviate  in  which  the  inflammatory 
process  is  confined  to  one-half  of  the  spinal  cord  or  to  small  cir- 
cumscribed areas.  In  the  first  event,  the  symptoms  of  a  unilateral 
lesion  of  the  spinal  cord  appear  acutely  (paralysis  and  hyperes- 
thesia upon  the  side  of  the  lesion,  and  anesthesia  upon  the  opposite 
side),  while  in  the  latter  they  depend  upon  the  varying  seat  of  the 
inflammatory  focus. 

Prognosis. — The  prognosis  of  acute  myelitis  is  grave,  as  there 
is  always  immediate  danger  (urinary  infection,  septicemia,  paral- 


ACUTE  INFLAMMATION  OF  THE  SPINAL  CORD         557 

ysis  of  cerebral  nerves),  or  the  disease  pursues  a  chronic  course ; 
complete  recovery  can  scarcely  be  expected. 

Treatment. — In  the  presence  of  acute  myelitis  an  ice-bag,  or, 
still  better,  the  ice-sac  of  Chapman,  should  be  applied  to  the  verte- 
bral colunan.  For  the  control  of  the  fever,  and  thereby  to  diminish 
the  flow  of  blood  to  the  spinal  cord,  sodium  salicylate  or  phenacetin 
should  be  prescribed : 

R   Sodium  salicylate,  1.0  (15  grains). 

Make  10  such  starch-capsules. 
Dose :  1  powder  every  two  hours. 

R  Phenacetin,  1.0(15    grains); 

Sugar,  0.5  (7i      "     ).— M. 

Make  10  such  powders. 
Dose:  1  powder  thrice  daily. 

The  diet  should  be  exclusively  liquid,  and  a  milk-diet  is  the 
best.  Strong  coffee  or  tea  and  wine  and  alcoholics  should  be  for- 
bidden. Daily  evacuation  of  the  bowels  should  be  secured,  and  to 
this  end  some  stewed  fruit  (apple-sauce,  prunes)  should  be  given 
at  the  midday  meal.  If  necessary,  laxatives  should  be  prescribed, 
and  glycerin-enemata  are  particularly  to  be  recommended.  It  is 
important  for  the  position  of  the  patient  to  be  changed  every  two 
hours,  in  order  to  avoid  persistent  pressure  upon  the  same  part  of 
the  skin.  Care  should  also  be  taken  to  have  the  sheet  always  free 
from  creases  and  that  it  does  not  contain  dry  bed-crumbs.  The 
entire  body  should  be  cleansed  with  tepid  water  at  least  once  daily, 
and  the  back  and  the  sacral  region  should  be  rubbed  with  some 
form  of  spirit,  cologne- water,  or  lemon-juice,  in  order  to  increase 
the  resistance  of  the  skin.  If  inflammation  of  the  skin  and 
bed-sores  threaten  in  spite  of  these  measures,  the  skin  should  be 
covered  with  smoothly  applied  adhesive  plaster,  and  the  patient 
should  be  placed  upon  an  air-mattress  or  a  water-bed.  The  great- 
est consideration  should  be  given  to  such  paralysis  of  the  bladder 
and  the  rectum  as  may  be  present.  If  retention  of  urine  occur, 
an  effort  should  first  be  made  to  evacuate  the  bladder  by  pressure 
through  the  abdominal  walls,  and  only  if  this  fails  should  resort 
be  had  to  the  use  of  the  catheter,  which  must  be  most  scrupu- 
lously disinfected.  If  dribbling  of  urine  be  present,  a  proper 
receptacle  should  be  provided.  If  the  skin  is  soiled  by  urine  or 
feces,  it  should  at  once  be  cleansed  and  washed  with  a  solution  of 
mercuric  chlorid  (1.0  :  1000).  If  a  bed-sore  be  present  when  the 
patient  comes  under  observation,  it  should  be  dressed  with  cotton 
that  has  been  immersed  in  spirit  of  camphor  or  the  patient  should 
be  placed  in  a  permanent  tepid  bath  (30°  C— 24°  R.— 86°  F.). 

The  foregoing  directions  for  the  care  of  the  patient  are  of  far 
greater  importance  than  any  medicament.  It  is  at  least  question- 
able whether  antiphlogistics  (mercurials,  leeches,  cups),  sorbefacients 
(potassium  iodid),  or  nervines  (bromids,  belladonna,  ergot,  arsenic, 


558  NERVOUS  SYSTEM 

preparations  of  gold  or  silver,  strychnin,  etc.)  are  capable  of  ex- 
erting any  effect.  Also  the  utility  of  electric  treatment  of  the 
spinal  cord  and  the  paralyzed  muscles  is  doubtful.  On  the  other 
hand,  resort  is  generally  had  to  massage  of  the  paralyzed  muscles, 
in  order  to  maintain  their  nutrition  and  avert  the  development  of 
contractures. 

CHRONIC  INFLAMMATION  OF  THE  SPINAL  CORD 
(CHRONIC  MYELITIS)* 

^Etiology. — Chronic  myelitis  is  dependent  upon  the  same 
causes  as  acute  myelitis,  and  accordingly  a  distinction  has  been 
made  principally  between  refrigeratory,  traumatic,  and  infectious 
chronic  myelitis.  Among  the  infectious  varieties  syphilitic  mye- 
litis should  be  particularly  mentioned.  Without  doubt,  alcoholism 
also  plays  an  etiologic  role,  and  under  such  circumstances  the 
myelitis  would  be  considered  toxic. 

Anatomic  Alterations. — Spinal  tissue  in  a  state  of  chronic 
inflammation  is  characterized  generally  by  increased  hardness  or 
sclerosis.  Not  alone  do  the  diseased  areas  feel  unusually  hard, 
but  they  also  appear  gray,  translucent,  and  shrunken.  It  is  note- 
worthy that  the  spinal  cord  may  appear  unaltered  in  the  fresh 
state,  although  after  hardening  in  preparations  of  chromic  acid,  as, 
for  instance,  Miiller's  fluid,  the  inflammatory  areas  can  be  recog- 
nized readily  from  their  light-yellow  color. 

On  microscopic  examination  hyperplasia  of  the  neuroglia  and  destruction 
of  nerve-fibers  and  ganglion-cells  will  be  found  in  the  inflamed  areas.  Of 
the  nerve-fibers,  the  medullary  sheaths  first  undergo  granular  disintegration 
and  fatty  degeneration.  The  disappearance  of  the  axis-cylinders  is  often 
preceded  by  marked  swelling.  The  ganglion-cells  undergo  contraction  to 
round  and  often  greatly  pigmented  structures,  without  processes.  The 
blood-vessels  appear  dilated  in  places,  are  distended  with  blood,  exhibit 
striated  and  thickened  walls  with  many  nuclei,  and  are  surrounded  on  their 
outer  surface  by  collections  of  round  cells.  The  adventitial  lymph-spaces 
also  not  rarely  contain  round  cells.  Fatty  granules  are  encountered  only  in 
small  number,  in  contradistinction  from  acute  myelitis,  while  amyloid  bodies 
are  present  in  considerably  greater  number. 

Chronic  myelitis  exhibits  the  same  distribution  as  acute  mye- 
litis. Disease  of  the  gray  matter  is  known  as  chronic  central  mye- 
litis or  chronic  poliomyelitis,  while  disease  of  the  white  matter  is 
designated  leukomyelitis.  Should  the  chronic  inflammatory  process 
remain  confined  to  the  peripheral  layers  of  the  white  matter  of 
the  spinal  cord,  the  condition  \s  de^iirniited.  a]so  chronic  perimyelitis. 
Under  the  conditions  last  named  the  spinal  membranes  are  fre- 
quently involved  in  the  inflammatory  process,  and  particularly  the 
pia  mater  and  the  arachnoid  undergo  thickening  and  adhesion — 
chronic  myelomeningitis.  For  the  same  reasons  that  are  applicable  to 
acute  myelitis  a  distinction  can  be  made  between  chronic  transverse 
myelitis,  unilateral  myelitis,  circnmscrihed,  diffuse,  and  c/i  ron  ic  myelitis. 

Symptoms,  Diagnosis,  and  Progfnosis. — When  chronic 


CHRONIC  INFLAMMATION  OF  THE  SPINAL   CORD       559 

myelitis  occurs  as  an  independent  disorder  it  generally  develops 
gradually.  Pains  in  the  course  of  the  vertebral  column,  a  sense 
of  constriction,  shooting  pains  in  the  arms  and  the  legs,  pares- 
thesise  in  the  lower  extremities,  and  at  times  also  vesical  disturb- 
ances are  often  complained  of  as  prodromes.  Most  commonly 
chronic  myelitis  is  situated  in  the  lumbar  or  dorsal  cord,  and  in 
conformity  with  this  fact  the  more  serious  disturbances  generally 
appear  first  in  the  lower  extremities.  The  legs  become  readily 
fatigued  in  walking,  the  knees  often  give  way,  and  the  patient 
stumbles  over  slight  irregularities  or  elevations  upon  the  floor. 
Fatigue  and  weakness  in  the  lower  extremities  progress  graduallv 
in  such  a  way  that  the  patient  shortly  resorts  to  the  use  of  crutches 
for  support.  Eventually  complete  paralysis  ensues,  and  the  patient 
is  kept  permanently  in  bed  or  in  a  chair.  To  the  motor  paralysis 
sensory  disturbances  are  generally  superadded,  most  commonlv 
more  or  less  marked  and  complete  anesthesia.  Vasomotor  and 
trophic  alterations  may  also  be  present.  The  tendinous  and  cutane- 
ous reflexes  are  abolished  when  the  inflammation  has  interrupted 
the  functional  activity  of  the  lumbar  cord.  Exaggeration  of  the 
reflexes  occurs  in  connection  with  transverse  myelitis  of  the  dorsal 
cord  when  secondary  degeneration  of  the  lateral  pyramidal  tracts 
takes  place  below  the  inflammatory  focus.  Then  muscular  con- 
tractures generally  develop,  most  commonly  in  the  flexors  of  the 
thigh  and  the  leg.  The  bladder  and  the  rectum  frequently  exhibit 
disturbances.  At  times  retention  and  incontinence  of  urine  alter- 
nate. Some  patients  complain  of  priapism  or  of  impotence.  Chronic 
myelitis  is  generally  unattended  with  fever.  At  times  transitory 
febrile  movement  occurs,  during  which  the  inflammatory  process 
advances.  At  times  it  extends  from  below  upward — chronic 
ascending  myelitis.  To  the  paralysis  of  the  lower  extremities 
there  is  then  superadded  paralysis  of  the  arms,  and  should  the 
process  extend  to  the  medulla  oblongata  and  the  pons  Varolii 
there  will  develop  paralysis  of  various  cerebral  nerves  (hypo- 
glossal, vago-accessory),  which  may  lead  to  a  fatal  termination  in 
consequence  of  paralysis  of  deglutition  or  of  the  heart. 

The  duration  of  the  disease  may  extend  over  many  years.  Re- 
covery is  possible  in  cases  that  are  not  too  far  advanced.  Gen- 
erally, however,  it  is  not  complete.  The  principal  dangers  are 
cystitis  and  urinary  infection  or  bed-sores  and  septicemia. 

Treatment. — The  treatment  of  chronic  myelitis  is  the  same 
as  that  of  acute  myelitis.  The  well-to-do  may,  in  addition,  under- 
take courses  of  treatment  at  the  baths  during  the  summer.  There 
may  be  mentioned  indifferent  baths  (Gastein,  Pfaffers,  Ragatz, 
Wildbad),  saline  baths  (Nauheim,  Rehme,  Kissingen,  Reichen- 
hall,  Rheinfelden,  Bex),  sulphur-baths  (Aachen,  Baden  in  Aargau, 
Baden  near  Vienna,  Schinzach,  Stachelberg,  Leuk,  Lenk,  Serneus), 
and  peat-baths  (Marienbad,  Franzensbad,  Elster,  Cudowa,  Steben). 


560 


NERVOUS  SYSTEM 


MULTIPLE  CEREBROSPINAL  SCLEROSIS, 

Etiology. — Little  of  a  reliable  nature  is  known  with  regard 
to  the  causes   of  multiple  cerebrospinal    sclerosis.     Exposure   to 
cold,  traumatism,  antecedent  infectious   disease,  and  intoxications 
(alcohol,  lead,  phosphorus,  carbon  raonoxid) 
are  considered  causes  of  the  disorder.     At 
times  the  disease  has  occurred  as  a  sequel 
of  the  puerperium.     In  some  cases  heredity 
has  been  observed  ;  in  others,  several  mem- 
bers of  a    family  have   been    attacked — 
familial  form.     The  disorder  generally  de- 
velops between  the  fifteenth  and  the  thirty- 
fifth  year  of  life.     It  occurs  but  rarely  in 
childhood,  although  isolated  cases  of  con- 
genital midfiple  sclerosis  hay e  been  reported. 
Anatomic     Alterations. — Multiple 
cerebrospinal  sclerosis  is  characterized  by 
the  formation  of  foci  of  neuroglia,  which 
-j^^  are  distributed  throughout  the  entire  central 

J         ^^^  nervous  system  in  varying  size,  number, 

and  arrangement.  The  white  nervous 
matter  everywhere  appears  particularly 
favored  by  the  foci  (Fig.  77).  The  indi- 
vidual foci  can  be  readily  recognized,  for 
when  of  sufficient  size  they  are  sharply 
differentiated  from  tlie  surrounding  healthy 
structure  by  their  reddish-gray  or  grayish 
color.  Generally  they  feel  indurated, 
whence  the  term  sclerosis.  Often  they 
can  be  detected  through  the  pia  mater,  so 
that  the  brain  and  the  spinal  cord  present 
I       ^^^^  ^  g^^yish,  mottled  appearance.     On  trans- 

verse section  of  the  spinal  cord  they  fre- 
quently become  depressed.  The  size  of  the 
foci  may  attain  several  centimeters  ;  but, 
on  the  other  hand,  it  may  be  so  inconsider- 
-«p^  able  that  the  smallest  foci  can  be  recog- 

^  ^^  nized  only  with  the  aid  of  a  microscope. 

Often  they  are  present  side  by  side  in  large 
number  and  above  one  another,  while  in 
other  instances  they  occur  in  but  small 
number.  Their  distribution  follows  no 
rule,  and  no  case  resembles  another.  In 
the  medulla  oblongata  sclerotic  areas  are 
not  rarely  found  in  the  nuclei  of  indi- 
vidual cerebral  nerves.  Similar  changes  have  been  observed  also 
in  the  trunk  of  cerebral  nerves. 


Fig.  77. — Transverse  sec- 
tions of  the  spinal  cord  from 
a  case  of  multiple  cerebro- 
spinal sclerosis,  in  a  man  3.5 
years  old:  a-d,  cervical  por- 
tion ;  f-k,  dorsal  portion : 
l-n,  lumbar  portion ;  natural 
size;  hardened  in  Muller's 
fluid  (personal  observation, 
Zurich  clinic). 


MULTIPLE  CEREBROSPINAL  SCLEROSIS  561 

Microscopic  examination  ^\?,c\o?,es  proliferation  of  the  neuroglia  and  destruc- 
tion of  the  nerve-fibers  in  the  sclerotic  areas.  It  is  noteworthy  that  the 
axis-cylinder  offers  resistance  for  a  long  time,  so  that  naked  axis-cylinders 
may  be  found  in  the  areas.  The  blood-vessels  further  exhibit  alterations, 
which  consist  in  thickening  of  their  wall,  nuclear  proliferation,  fatty  degen- 
eration and  the  presence  of  round  cells,  fatty  granule-cells,  and  also  yellow- 
ish flakes  of  pigment  in  the  adventitial  lyniph-sheaths.  The  cells  in  the 
sclerotic  foci  have  been  thought  to  consist,  in  part,  of  emigrated  colorless 
blood-corpuscles.  Fatty  granule-cells,  and  particularly  amyloid  bodies,  are 
frequently  encountered  in  the  sclerotic  areas.  In  all  probability  multiple 
cerebrospinal  sclerosis  must  be  considered  as  a  form  of  disseminated  chronic 
myelitis,  the  inflammatory  irritant  being  brought  to  the  spinal  cord  through 
the  blood-vessels. 

Symptoms. — The  distinctive  symptoms  of  multiple  cerebro- 
spinal sclerosis  are  generally  preceded  by  prodromes  of  an  indef- 
inite character.  These  include  vertigo,  headache,  paresthesias, 
neuralgia,  disturbances  of  the  bladder,  and  paroxysmal  vomiting 
(gastric  crises).  The  disease  can  be  recognized  only  when  typical 
symptoms  make  their  appearance,  including  intention-tremor,  scan- 
ning speech,  nystagmus,  and  apoplectiform  attacks.  Intention- 
tremor  may  be  recognized  from  the  fact  that  when  the  patients 
wish  to  execute  a  movement  the  members  set  in  action  begin  to 
tremble  actively  or  generally  to  shake,  and  in  greater  degree  the 
more  nearly  they  approach  the  consummation  of  the  act.  If  the 
patient  attempts  to  touch  with  his  fingers  a  body  held  before  him, 
the  arms  and  hands  are  thrown  to  and  fro.  TJie  introduction  of 
a  needle  into  a  previously  made  perforation  is  scarcely  possible, 
because  the  fingers  and  the  needle  are  too  actively  moved  to  and 
fro  upon  the  paper.  On  attempts  to  carry  a  glass  or  a  spoon  to 
the  mouth  the  contents  are  partially  spilt  by  the  sliaking  of  the 
arm,  and  the  rattling  of  the  teeth  can  be  heard.  Writing,  sewing, 
dressing,  buttoning  are  naturally  disturbed  in  marked  degree,  and 
they  may  even  be  rendered  impossible.  On  sitting  erect,  in  AA^alk- 
ing,  and  in  the  use  of  a  stick  the  oscillating  and  tremulous  move- 
ments may  be  readily  observed. 

Opinions  are  divided  as  to  the  7node  of  origin  of  intention-tremor.  It  has 
been  thought  that  the  naked  axis-cylinders  in  the  sclerotic  areas  are  capa- 
ble of  transmitting  the  impulses  of  the  will  only  interruptedly.  According 
to  others,  transverse  radiation  is  believed  to  be  possible  from  non-medul- 
lated  nerve-fibers,  and  thus  to  disturb  the  normal  transmission  of  volitional 
impulses.  It  is  less  probable  that  intention-tremor  is  dependent  upon  the 
presence  of  sclerotic  areas  in  definite  portions  of  the  brain,  as  the  phenom- 
enon is  a  most  constant  and  early  manifestation,  so  that  it  would  be  neces- 
sary to  assume  the  presence  invariably  of  early  disease  of  definite  portions 
of  the  brain,  Avhereas  the  disorder  is  characterized  especially  by  the  irreg- 
ular distribution  of  the  foci  of  disease. 

Scanning  speech  is  characterized,  in  the  first  place,  by  the  ar- 
ticulation of  the  individual  syllables  of  a  word  in  jerks  and  with 
pauses,  and,  besides,  by  the  peculiar,  monotonous,  singing,  and 
high-pitched  character  of  the  voice.     The  disturbances  of  speech 

.36 


562  NERVOUS  SYSTEM 

are  thought  to  be  dependent  upon  intention-tremor  of  the  muscles 
of  articulation  and  of  the  larynx  or  of  the  vocal  bands.  Not 
rarely  most  marked  distortion  of  the  face  is  observed  on  attempts 
to  speak.  A  patient  under  ray  care  was  capable  of  speaking  only 
by  holding  the  lower  jaw  firmly  with  her  hands,  and  keeping  it 
at  rest.  Sudden  dilatation  of  the  chink  of  the  glottis  and  trem- 
ulous movements  of  the  vocal  bands  during  phonation  have  also 
been  observed  on  laryngoscopic  examination. 

The  nystagmus  is  likewise  due  to  intention-tremor  of  the  ocular 
muscles.  It  can  be  readily  recognized  from  the  horizontal  to-and- 
fro  movement  of  the  eyes  that  takes  place  when  a  finger  is  moved 
to  and  fro  in  a  horizontal  direction,  and  which  becomes  the  more 
marked  the  further  the  finger  is  moved  outward.  Rarely,  twitch- 
ing movements  in  a  vertical  direction  or  rotatory  movements 
occur — vertical  and  rotatory  nystagmus.  Nystagmus  occurs  rather 
less  constantly  than  intention-tremor  and  scanning  speech,  and  is 
present  in  about  one-half  of  the  cases. 

Apoplectic  attacks  occur  still  less  commonly.  Consciousness 
is  lost,  and  wdien  it  is  restored  the  patient  finds  himself  paralyzed 
upon  one  side  of  the  body  or  in  one  member ;  but,  as  a  rule,  the 
paralysis  disappears  in  the  course  of  a  few  days.  There  is  a  dis- 
position to  attribute  such  attacks,  wdiich  not  rarely  are  attended 
with  elevation  of  temperature  and  are  at  times  accompanied  also 
bv  eclamptic  convulsions,  to  the  development  of  new  sclerotic  areas. 

The  typical  symptoms  of  multiple  cerebrospinal  sclerosis  must 
be  distinguished  from  the  more  accidental  nervous  disturbances, 
which  vary  accordingly  as  one  or  another  portion  of  the  central 
nervous  system  is  the  seat  of  the  sclerotic  process,  and  is  thus 
thrown  out  of  function.  As  of  the  anatomic  alterations,  it  may 
likewise  be  said  of  this  group  of  symptoms  that  one  case  scarcely 
resembles  wholly  any  other. 

Of  diagnostic  significance  are  particularly  atrophic  changes  in 
the  optic  nerve,  which  preferably  involve  the  temporal  half  of  the 
optic  papilla.  At  times  disturbances  occur  also  in  other  cerebral 
nerves  (paralysis  of  the  ocular  muscles,  of  the  trigeminus,  of  the 
vagus,  tinnitus  aurium,  impairment  of  hearing,  immobility  of  the 
tongue,  etc.).  Frequently  motor  disturbances  appear,  particularly 
paresis  or  paralysis  in  the  lower  extremities.  These  are  often 
associated  with  muscular  spasm  and  exaggeration  of  the  tendon- 
reflexes.  The  gait  becomes  spastic-paretic,  and  the  clinical  picture 
resembles  that  of  so-called  spastic  spinal  paralysis.  Sensory  dis- 
turbances, generally  partial  anesthesia,  are  also  not  uncommon 
occurrences.  At  times  jKiralysis  of  the  bladder  develops,  which 
may  subside,  subsequently,  however,  to  reappear. 

If  groups  of  ganglion-cells  in  the  anterior  horns  of  the  spinal 
cord  are  destroyed  by  the  sclerotic  process,  muscular  paralysis 
with  degenerative  atrophy  and  degenerative  electric  reaction  may 


MULTIPLE  CEREBROSPINAL  SCLEROSIS  563 

result.  When  paralysis  has  existed  for  some  time  muscular  con- 
tractures may  develop,  frequently  earliest  in  the  adductors  of  the 
thighs,  subsequently  in  the  flexors  of  the  thighs,  the  legs,  and  the 
feet.  Extensive  foci  in  the  vicinity  of  the  posterior  columns  of 
the  spinal  cord  render  the  gait  ataxic,  and  under  such  conditions 
confusion  with  tabes  dorsalis  may  arise. 

Vasomotor  and  trophic  disturbances  have  been  observed,  but 
are  among  the  less  common  manifestations.  The  mental  condition 
not  rarely  suffers.  The  patients  become  more  and  more  apathetic, 
forgetful,  and  finally  demented.  Sometimes  uncontrollable  laugh- 
ter is  observed  at  an  early  stage,  long-continued  laughter  of  an 
unusually  hearty,  almost  boisterous  character  being  induced  on 
slight  provocation.     Uncontrollable  crying  also  may  occur. 

The  course  of  multiple  cerebrospinal  sclerosis  frequently  ex- 
tends over  many  years,  and  often  remissions  and  exacerbations  in 
the  symptoms  alternate.  Death  results  from  accidental  disease 
(pulmonary  tuberculosis,  pneumonia,  etc.),  or  from  excessive  ex- 
haustion, or  from  urinary  infection  in  the  presence  of  paralysis 
of  the  bladder,  or  from  septicemia  in  consequence  of  bed-sores,  or 
from  bulbar  paralysis  (paralysis  of  swallowing  and  of  respiration). 

Diagnosis. — The  diagnosis  of  multiple  cerebrospinal  sclero- 
sis is  easy  in  typical  cases.  Naturally,  emphasis  must  be  placed 
upon  the  fact  that  there  is  a  neurosis  of  the  central  nervous  system 
— so-called  pseudosclerosis — which  may  exactly  reproduce  the 
clinical  picture  of  multiple  sclerosis,  although  upon  post-mortem 
examination  the  central  nervous  system  may  be  found  unchanged. 
The  occurrence  of  atrophy  of  the  optic  nerve  is  distinctive  of 
cerebrospinal  sclerosis. 

Intention-tremor  occurs  at  times  also  in  association  with  cerebral  tumors, 
mercurial  poisoning,  and  hysteria ;  but  under  such  conditions  the  remain- 
ing symptoms  of  multiple  sclerosis  will  be  wanting. 

Should  the  typical  symptoms  of  the  disease  already  described 
be  absent,  it  will  scarcely  be  possible  to  make  the  diagnosis  with 
certainty.  The  disease  may  then  be  readily  confounded  with 
chronic  myelitis,  tabes  dorsalis,  spastic  spinal  paralysis,  and  amyo- 
trophic lateral  sclerosis.  Confusion  with  paretic  dementia  is  also 
possible.  Further,  it  should  be  borne  in  mind  that  no  invariable 
relation  exists  between  the  severity  of  the  morbid  manifestations 
and  the  extent  of  the  anatomic  alterations. 

Prognosis. — Multiple  cerebrospinal  sclerosis  is  an  incurable 
disease,  and  from  this  point  of  view  the  prognosis  is  unfavorable. 
It  is  true  that  at  times  such  remarkable  improvement  occurs  as  to 
encourage  the  hope  of  recovery,  but  this  proves  deceptive.  There 
is,  however,  no  immediate  danger  of  death. 

Treatment. — No  specific  remedy  for  multiple  sclerosis  is 
known,  and,  in  general,  the  rules  should  be  followed  that  have 
been  laid  down  on  p.  485  for  the  treatment  of  myelitis. 


564  NERVOUS  SYSTEM 

TUMORS  OF  THE   SPINAL   CORD. 

Tumors  of  the  spinal  cord  are  not  uncommon  :  gliomata,  sarco- 
mata, carcinomata,  myxomata,  cholesteatomata,  gummata,  and  tuber- 
culomata  have  been  ol)served. 

Anatomic  Alterations. — Tumors  of  tlie  spinal  cord  are 
generally  of  spherical  form,  l)ut  at  times  they  involve  the  entire 
transverse  section  or  one-half  or  a  still  smaller  section  of  the  spinal 
cord,  or  they  may  extend  throughout  the  length  of  the  cord  from 
above  downward.  At  times  they  are  clearly  defined  from  the 
surrounding  spinal  tissue  by  a  connective-tissue  capsule,  but  at 
other  times  they  gradually  merge  into  the  structure  of  the  cord. 
Often  the  latter  is  softened  at  the  point  of  junction.  In  the 
tumors  themselves  softening  and  the  formation  of  cavities  may 
also  take  place.  In  tumors  well  supplied  with  blood-vessels  ex- 
tensive hemorrhage  may  suddenly  occur,  with  destruction  of  the 
neoplastic  tissue  and  of  the  adjacent  tissue  of  the  cord. 

The  causes  for  tumors  of  the  spinal  cord  are  often  unknown. 
At  times  traumatism,  pregnancy,  and  the  puerperium  are  named 
as  causes.  At  times  the  tumors  are  of  metastatic  origin.  Gum- 
mata and  tuberculomata  are  sequels  of  syphilis  and  tuberculosis 
respectively. 

The  diagnosis  of  a  spinal  tumor  is  scarcely  ever  possible. 
This  is  a  matter  of  course  for  cases  in  which  spinal  symptoms  are 
wholly  wanting.  The  same  condition  also  prevails  at  times  in 
connection  with  relatively  extensive  neoplasms  if  these  displace 
rather  than  destroy  the  nervous  elements  of  the  cord.  Under 
other  circumstances,  in  accordance  with  the  seat  and  the  extent 
of  the  new-growth,  symptoms  of  transverse  interruption  or  of  a 
unilateral  lesion  of  the  cord,  of  anterior  poliomyelitis,  syringo- 
myelia, spastic  spinal  paralysis,  tabes  dorsalis,  and  the  like,  may  be 
present,  and  only  the  autopsy  may  reveal  the  causes  for  the  spinal 
disturbances. 

The  progtiosis  is  serious.  Death  results  generally  from 
progressive  exhaustion,  in  the  presence  of  paralysis  of  the  bladder 
from  urinary  infection  and  in  the  presence  of  bed-sores  from  sep- 
ticemia. 

Specific  treatment  is  applicable  only  when  syphilis  is  present, 
but  otherwise  the  treatment  applicable  to  myelitis  should  be  em- 
ployed (p.  557). 

CAVITIES  IN  THE  SPINAL  CORD  (SYRINGOMYELIA 
AND  HYDROMYELIA). 

Anatomic  Alterations. — The  presence  of  cavities  in  the 
spinal  cord  is  at  times  due  to  morbid  dilatation  of  the  central 
canal,  and  the  condition  is  then   designated  hydromyelia.     It  is 


CAVITIES  IN  THE  SPINAL  CORD 


565 


characterized  by  the  presence  in  places  of  cylinclric  epithelium 
upon  the  walls  of  the  cavity.  The 
disorder  has  been  observed  particu- 
larly in  connection  with  tumors  in 
the  posterior  fossa  of  the  skull,  and 
it  has  been  attributed  to  stasis.  Most 
cavities  in  the  spinal  cord  result  from 
gliosis  (gliomatosis) ;  that  is,  prolifer- 
ation of  neuroglia  first  takes  place, 
which  not  rarely  extends  throughout 
the  entire  length  of  the  spinal  cord, 
and  even  through  the  medulla  ob- 
longata, and  then  by  the  softening 
of  this  tissue  a  cavity  results — syrin- 
gomyelia. Less  commonly  cavities 
result  from  softening  of  myelitic  foci 
or  of  tumors  of  the  spinal  cord. 

Hydrorayelia  and  syringomyelia 
are  by  no  means  always  easily  and 
with  certainty  distinguishable  from 
each  other,  for  when  syringomyelia 
is  present  rupture  into  the  central 
canal  occasionally  takes  place,  and 
there  may  be  subsequent  dilatation 
of  the  central  canal,  and  the  walls 
of  the  cavity  then  likewise  present 
cylindric  epithelium  in  places.  The 
cavity  in  a  case  of  syringomyelia  may 
involve  the  entire  spinal  cord  and 
also  the  medulla  oblongata,  and  it 
may  terminate  in  the  fourth  ventri- 
cle, or  it  may  develop  for  only  a 
short  distance  at  a  single  yioint  or 
at  several  points  in  the  spinal  cord. 
Most  commonly  the  cervical  cord  is 
the  seat  of  the  disease,  and  in  this 
situation  the  cavity  usually  attains 
its  greatest  size.  In  the  course  of 
the  spinal  cord  the  cavity  often  al- 
ters its  position  (Fig.  78).  At  times 
it  is  situated  between  the  posterior 
columns  of  the  spinal  cord,  while  at 
other  times  it  involves  the  gray  mat- 
ter of  the  cord,  now  in  the  neighbor- 
hood of  the  anterior  horns,  where  it 
causes  destruction  of  tiie  lars^e  mo- 
tor-trophic  ganglion-cells,  then  in  the  neighborhood  of  the  posterior 


Medulla  oblonsata 


Cervical  nerve,  l-2~ 


Cervical  nerve,  1-2 — 


Dorsal  nerve,  1-2- 


Dorsal  nerve,  2-3 — 


Dorsal  nerve,  4- 


Dorsal  nerve,  8-0- 


Dorsal  nerve,  lf-11 — 


Dorsal  nerve,  11-12 1 


Lumbar  nerve,  3-4  — 


Lumbar  nerve,  4-5- — 


Lumbar  nerve,  4-5- 


Fig.  78.— Syringomyelia  in  a  woman 
29  years  old  ;  natural  size  (personal  ob- 
servation). 


566  yERVOUS  SYSTEM 

horns,  in  other  situations  in  the  middle  portion  of  the  gray  matter, 
etc.  The  size  of  the  cavity  varies  from  the  scarcely  visible  to  such 
an  extent  that  the  tip  of  the  little  finger  can  be  readily  introduced. 
Under  the  latter  condition  the  entire  transverse  section  of  the  cord 
is  increased  in  size.  The  spinal  cord  not  rarely  resembles  a  fluctu- 
ating sac  oscillating  to  and  fro,  and  which  on  incision  gives  exit  to 
a  generally  clear  and  but  rarely  flocculent  or  blood-stained  fluid, 
and  which  collapses  after  evacuation.  The  cavity  is  generally 
provided  with  a  membrane  formed  of  dense  neuroglia.  The  blood- 
vessels are  generally  thickened  and  obstructed  by  thrombi,  condi- 
tions that  are  associated  with  the  softening  of  the  neuroglia  and 
the  formation  of  the  cavity.  Often  yellowish  and  brownish  pig- 
ment is  encountered  in  the  neighborhood  of  the  cavity.  The 
adjacent  columns  of  the  spinal  cord  are  not  rarely  sclerotic. 

Btiology. — Syringomyelia  is  probably  in  many  cases  de- 
pendent upon  developmental  defects  in  the  spinal  cord  that 
undergo  further  development  as  a  result  of  accidental  influences. 
The  latter  include  particularly  traumatism  and  antecedent  infectious 
disease.  Hereditary  and  familial  occurrence  of  syringomyelia  has 
also  been  observed.     The  condition  generally  appears  in  adults. 

Symptoms. — An  extensive  cavity  in  the  spinal  cord  may  be 
w^holly  unattended  with  symptoms.  Among  the  distinctive  mani- 
festations of  syringomyelia  are  progressive  muscular  atrophy,  partial 
loss  of  sensibility,  and  vasomotor  and  trophic  changes. 

Progressive  muscular  atrophy  generally  begins,  like  typical 
spinal  muscular  atrophy,  in  the  muscles  of  the  thenar  and  hypo- 
thenar  eminences  and  in  the  interosseous  muscles.  Xext,  the 
extensor  muscles  upon  the  dorsal  aspect  of  the  forearm  and  the 
deltoid  are  involved.  The  muscles  waste  progressively,  become 
correspondingly  weaker,  exhibit  fascicular  (fibrillary)  contractions 
and  deg-enerative  electric  reaction.  The  condition  can  scarcelv  be 
differentiated  from  chronic  anterior  poliomyelitis,  upon  which 
spinal  progressive  muscular  atrophy  depends,  if  partial  anesthesia 
also  is  not  present.  The  development  of  the  symptoms  is  readily 
explained  by  the  fact  that  the  cavity  has  destroyed  the  large 
motor-trophic  ganglion-cells  in  the  anterior  horns  of  the  spinal 
cord. 

Partial  anesthesia  occurs  in  cases  of  syringomyelia  together 
with  or  independently  of  progressive  muscular  atrophy,  and  is  due 
to  destruction  of  the  posterior  horns  of  the  spinal  cord,  through 
which  pass  the  paths  for  painful  and  thermal  sensibility.  It  is  not 
surprising,  therefore,  that  loss  of  painful  and  thermal  sensibility 
occurs.  Needle-pricks  are  often  appreciated  only  as  touch.  Often 
the  skin  is  marked  by  the  wounds  of  burns,  which  are  frequently 
acquired  from  contact  with  a  stove,  the  attention  of  the  patients 
not  being  attracted  to  their  wounds  by  the  pain,  but  by  the  odor, 
of  burning  tissue.     At  times  cold  is  felt  as  warm,  and  vice  versa. 


SPINAL   COMPRESSION-PARALYSIS  567 

Among  the  trophic  disorders  ulceration,  particularly  on  the 
fingers,  should  be  mentioned,  occurring  and  persisting  without 
pain.  At  times  also  the  terminal  phalanges  are  exfoliated  with- 
out pain.  Often  the  phalanges  become  peculiarly  shortened  and 
thickened.  Not  rarely  contracture  of  the  aponeurosis  of  the  hand 
is  observed.  Marked  kyphoscoliosis  in  the  upper  dorsal  portion  of 
the  spinal  column  frequently  develops.  At  times  painless  fissures 
form  upon  the  fingers.  Bullae  also  often  form,  suggestive  of 
herpes  or  pemphigus.  At  times  a  perforating  ulcer  develops. 
Spontaneous  fracture  of  bones  and  alterations  in  joints  are  also 
known  to  occur. 

Among  vasomotor  manifestations  erythema,  edema  of  the  hands 
or  feet,  anidrosis  and  hyperidrosis  may  be  mentioned.  Not  rarely 
inequality  of  the  pupils  exists.  Bulbar  symptoms  also  develop 
when  the  cavity  has  invaded  the  medulla  oblongata.  Among  the 
symptoms  may  be  mentioned  atrophy  of  the  tongue,  unilateral 
facial  atrophy,  paralysis  of  deglutition,  paralysis  of  the  muscles  of 
the  vocal  bands,  accelerated  action  of  the  heart,  glycosuria,  and 
polyuria.     At  times  paralysis  of  the  ocular  muscles  develops. 

Optic  neuritis  and  contraction  of  the  visual  field  also  have  been 
observed  in  a  number  of  instances.  At  times  the  patients  have 
exhibited  ataxia  or  a  spastic-paretic  gait. 

The  course  of  syringomyelia  is  chronic.  Death  results  from 
accidental  diseases,  progressive  marasmus,  bulbar  paralysis,  bed- 
sores, or  septicemia. 

Diagnosis. — The  recognition  of  syringomyelia  is  easy  in 
typical  cases.  Some  of  the  symptoms  are  suggestive  of  nervous 
leprosy,  but  this  disease  occurs  only  in  the  tropics,  and  can  be 
recognized  bacterioscopically  from  the  presence  of  leprosy -bacilli. 
The  symptom-complex  described  by  Morvan,  and  designated 
Morvan^s  disease,  and  which  is  characterized  especially  by  inflam- 
mation and  painless  exfoliation  of  the  terminal  phalanges,  is  only 
syringomyelia. 

Prognosis. — Syringomyelia  is  an  incurable  disease,  and  its 
prognosis  is  therefore  unfavorable.  Life  may,  however,  be  main- 
tained for  many  years. 

Treatment. — The  treatment  is  limited  to  the  relief  of  partic- 
ularly troublesome  or  dangerous  symptoms. 

SPINAL  COMPRESSION-PARALYSIS. 

Etiology. — Spinal  pressure-paralysis  results  most  commonly 
in  consequence  of  disease  of  the  spinal  column.  Tuberculosis  of 
the  vertebrae  particularly,  carcinoma  of  the  vertebrae  less  com- 
monly, give  rise  to  spinal  pressure-paralysis.  The  condition  may 
result  also  from  luxation  or  fracture  of  the  vertebrae,  from  arthritic 
or  syphilitic  exostoses,  from  thickening  of  the  odontoid  process, 


568  NERVOUS  SYSTEM 

and  the  like.  At  times  processes  that  exert  pressure  upon  the 
spinal  cord  enter  the  vertebral  canal  from  without ;  for  instance, 
cheesy-tuberculous  inflammation  extending  from  the  pleural  cavity 
through  the  intervertebral  foramina  into  the  spinal  canal ;  carci- 
nomatous changes  in  the  kidney,  which  have  followed  the  same 
path  in  their  extension ;  aortic  aneurysm,  first  perforating  the 
vertebral  column  and  then  compressing  the  spinal  cord ;  and  dis- 
integrating carcinoma  of  the  esophagus,  which  injures  the  spinal 
cord  after  destruction  of  the  vertebral  column.  Pressure  upon 
the  spinal  cord  sometimes  arises  from  the  spinal  membranes,  and 
occurs  particularly  in  connection  with  meningeal  hemorrhage, 
inflammation,  and  neoplasm.  Disease  of  the  spinal  cord  itself  is 
also  easily  capable  of  exerting  injurious  pressure  upon  the  dis- 
eased organ,  particularly  progressively  growing  tumors  of  the 
spinal  cord.  Spinal  pressure-paralysis  may  occur  at  any  period 
of  life.  Thus,  it  is  not  rarely  induced  in  children  by  tuberculosis 
of  the  vertebrae. 

Anatomic  Alterations. — Spinal  pressure-paralysis  is  fre- 
quently attended  with  alterations  in  the  vertebral  column,  partic- 
ularly kyphosis  (gibbus).  Under  such  conditions  it  may  be 
inferred  that  stenosis  of  the  vertebral  canal  is  responsible  for  the 
compression  of  the  spinal  cord,  although  snch  an  occurrence  is  but 
seldom  actually  encountered.  In  the  majority  of  cases  the  inflam- 
mation of  the  vertebrae  or  in  the  vicinity  gives  rise  to  inflamma- 
tion upon  the  outer  surface  of  the  spinal  dura  niater — external 
spinal  pachymeningitis — and  the  pressure  upon  the  spinal  cord 
results  as  a  secondary  consequence.  In  the  presence  of  tubercu- 
losis of  the  diseased  vertel)r8e  it  is  the  rule,  for  instance,  that  in  the 
vicinity  of  the  diseased  vertebrae  thick,  cheesy-tuberculous  masses 
are  present  upon  the  outer  surface  of  the  dura,  and  these  represent 
the  actual  cause  of  the  compression.  The  eifects  of  the  alterations 
named  upon  the  spinal  cord  itself  are  variable.  In  some  cases  the 
spinal  cord  appears  compressed,  diminished  in  size,  marked  by  a 
deep  constriction,  and  not  rarely  hardened  or  sclerotic,  although 
these  occurrences  are  rather  infrequent.  More  commonly  either 
the  spinal  cord  exhibits  no  alteration  in  size  at  the  point  of  com- 
pression or  it  is  widened,  and  on  touch  is  found  nnusually  soft. 
On  transverse  section  it  rises  above  the  level  of  the  cut  surface, 
appears  of  grayish  or  reddish-gray  color,  and  its  cut  surface  fails 
to  ])resent  the  usual  appearance  or  presents  it  but  imperfectly. 
Also,  after  the  spinal  cord  has  been  hardened  in  Miiller's  fluid  the 
confused  appearance  of  the  cut  surface  is  visible,  and  even  more 
distinctly  than  in  the  fresh  state.  Besides,  it  will  be  found,  if  the 
disease  has  existed  for  a  considerable  length  of  time,  that  second- 
ary degeneration  of  the  anterior  and  lateral  pyramidal  tracts  below 
and  of  the  columns  of  Goll,  the  lateral  cerebellar  tracts,  and 
Gowers'  bundle  above  the  point  of  compression  has  taken  place. 


SPINAL  COMPRESSWN-PABALYSIS  569 

Microscopic  examination  discloses  degeneration  of  nerve-fibers  at  the 
point  of  compression.  Often  naked  axis-cylinders,  whose  medullary  sheaths 
have  been  destroyed  by  granular  disintegration  and  fatty  degeneration,  are 
conspicuous  for  their  marked  swelling.  The  neuroglia  appears  increased 
and  generally  contains  numerous  fatty  granule-cells.  The  blood-vessels  are 
often  greatly  distended  and  markedly  tortuous.  Here  and  there  collec- 
tions of  round  cells  are  present  in  the  neighborhood  of  the  blood-vessels. 
In  the  gray  matter  of  the  spinal  cord  the  ganglion-cells  undergo  swelling 
at  first,  and  frequently  present  vacuoles ;  subsequently  they  shrink  into 
small  structures  without  processes.  It  was  formerly  believed  that  all  of 
these  symptoms  were  inflammatory,  and  therefore  the  designation  compres- 
sion-myelitis has  also  been  employed ;  but  this  is  inappropriate,  because  the 
alterations  are  often  in  the  main  the  results  of  anemic  states  and  venous 
stasis,  which  necessarily  are  followed  by  the  alterations  in  the  meninges. 

Symptoms  and  Diagnosis. — The  symptoms  of  spinal  press- 
ure-paralysis are  frequently  preceded  by  prodromal  local  alterations 
in  the  vertebral  column,  particularly  circumscribed  spinal  pain, 
appearing  spontaneously  or  upon  pressure,  and  distortion  of  the 
spinal  coliunn,  and  at  times  also  burrowing  abscesses.  Patients 
also  often  complain  of  a  constricting  girdle  or  hoop-like  sensation 
about  the  trunk,  which  is  induced  by  irritation  of  posterior  nerve- 
roots.  The  distinctive  symptoms  of  compression  of  the  spinal  cord 
t!onsist  in  signs  of  transverse  interruption  of  the  functions  of  the 
cord.  At  first  these  are  incomplete,  and  involve  the  motor  paths 
alone  or  principally,  whilst  subsequently  sensory  disturbances  also 
become  apparent.  The  predominance  of  motor  symptoms  is  ex- 
plained by  the  fact  that  pressure-paralysis  of  the  spinal  cord  is 
often  associated  with  disease  of  the  vertebral  column,  and  this 
generally  arises  from  the  bodies  of  the  vertebrae,  which  are  in 
close  proximity  to  the  motor  paths  of  the  spinal  cord.  Besides, 
as  has  been  determined  by  experiments  upon  animals,  the  motor 
nerves  offer  less  resistance  to  pressure  than  the  sensory  nerves. 

Frequently  the  clinical  picture  begins  with  weakness  in  the 
lower  extremities,  which  more  or  less  quickly  becomes  transformed 
into  complete  j9ara/?/sis  and  compels  the  patients  to  remain  in  bed. 
The  paralysis  is  at  first  flaccid.  If  the  focus  of  pressure  is  situated 
in  the  upper  portion  of  the  cervical  cord,  the  arms  in  addition  to  the 
legs  will  be  paralyzed.  The  tendon-reflexes,  as  well  as  the  cutane- 
ous reflexes,  are  generally  increased.  Often  vesical  disturbances 
are  present,  consisting  at  first  in  retention  of  urine  (detrusor- 
paralysis),  and  subsequently  in  incontinence  of  urine  (sphincter- 
paralysis).  In  consequence  there  may  arise  the  danger  of  alkaline 
decomposition  of  the  urine,  cystitis,  pyelonephritis,  urinary  infec- 
tion, bed-sores,  and  septicemia.  Paralysis  of  the  rectum  also  occurs 
frequently,  and  increases  the  danger  of  bed-sores  and  septicemia. 
The  patients  often  complain  of  muscular  twitching  in  the  paralyzed 
members,  and  this  may  occur  spontaneously  or  result  from  reflex 
irritation  on  palpation  of  the  extremities,  and  is  at  times  attended 
with  severe  pain.     Not  rarely  severe  shooting  j^ain  occurs  parox- 


570  NERVOUS  SYSTEM 

ysmally  in  the  paralyzed  extremities.  Paresthesice  (formication, 
tingling,  prickling,  burning,  a  sense  of  cold)  also  occur.  Cutaneous- 
anedhesia,  in  conjunction  with  paralysis,  indicates  almost  total 
transverse  interruption  of  the  spinal  cord.  At  first  it  is  often  in- 
complete, subsequently,  however,  becoming  complete.  Should 
demonstrable  alterations  in  the  vertebral  column  be  absent,  it  will 
be  important  to  determine  the  upper  limit  of  anesthesia  in  order 
to  localize  the  seat  of  pressure.  Vasomotor  and  trophic  disturb- 
ances (abnormal  color  of  the  skin,  anidrosis,  hyperidrosis,  the  for- 
mation of  blisters)  are  not  rarely  observed. 

The  course  of  the  disease  is  generally  chronic  ;  either  there  is  a 
tendency  to  progressive  aggravation,  or  periods  of  improvement 
and  exacerbation  frequently  alternate  with  each  other.  Recovery 
is  not  impossible  when  the  focus  of  pressure  disappears  and  the 
compression  of  the  spinal  cord  itself  has  not  given  rise  to  altera- 
tions in  the  substance  of  the  cord  of  too  serious  a  nature.  When 
paralysis  has  existed  for  a  considerable  length  of  time,  muscular 
contractures  often  develop,  at  first  generally  in  the  extensors,  but 
subsequently  in  the  flexors  of  the  thighs  and  the  legs. 

The  diagnosis  of  a  transvei^se  lesion  of  the  spinal  cord  is  in 
itself  generally  easy,  but  insurmountable  difficulties  may  arise  in 
endeavoring  to  attribute  the  disturbance  to  spinal  compression. 
In  this  connection  the  fact  whether  local  alterations  in  the  ver- 
tebral column  (painful  pressure-points,  but  especially  deformities 
of  the  spinal  column)  are  present  or  not,  is  particularly  important. 
Should  these  be  absent  the  diagnosis  will  remain  doubtful.  The  de- 
termination of  the  nature  of  the  compressing  influence  is  also  fre- 
quently attended  with  difficulty,,  In  early  life  pressure-paralysis 
of  apparently  spontaneous  origin,  with  a  projection  of  the  verte- 
bral column,  generally  depends  upon  tuberculosis  of  the  vertebrse. 
The  presence  of  painful  anesthesia  is  to  a  certain  degree  distinc- 
tive of  carcinoma  of  the  vertebrse.  The  patient  under  such  cir- 
cumstances complains  of  the  most  intense  pain  in  the  extremities, 
whose  cutaneous  covering  is  totally  insensitive.  The  condition  is 
explained  by  the  fact  that  the  pressure  of  the  new-growth  upon 
the  posterior  spinal  nerve-roots  has  interrupted  the  transmission 
of  sensory  impulses  from  the  periphery  to  the  brain,  although 
irritation  of  the  central  terminations  of  the  nerve-roots  induces 
severe  pain  that  is  referred  to  the  periphery.  In  order  to  deter- 
mine the  cause  of  pressure-paralysis  all  the  organs  in  proximity 
to  the  vertebral  column  should  be  examined  most  carefully. 

Progfnosis. — The  prognosis  of  spinal  pressure-paralysis  is 
unfavorable  under  all  conditions.  Progressive  exhaustion,  paral- 
ysis of  the  bladder  and  urinary  infection,  bed-sores  and  septi- 
cemia, are  the  principal  dangers.  Some  of  the  causes  of  compres- 
sion (carcinoma,  aneurysm  of  the  aorta)  render  the  prognosis 
unfavorable  by  reason  of  their  incurable  nature. 


UNILATERAL  LESIONS  OF  THE  SPINAL   CORD 


571 


Treatment. — Causal  treatment  should  be  employed  when  the 
pressure  is  of  syphilitic  origin,  and  it  should  consist  in  inunctions 
of  mercurial  ointment  and  the  internal  administration  of  potas- 
sium iodid  (5.0:200 — 75  grains  :  Gg^  fluidounces  ;  15  c.c. — 1 
tablespoonful — thrice  daily).  Rest  is  necessary  under  all  cir- 
cumstances. In  addition,  an  ice-bag  should  be  applied  contin- 
uously over  the  focus  of  disease,  and  massage  of  the  paralyzed 
members  should  be  practised.  Internally,  potassium  iodid  may 
be  essayed.  Recently  the  vertebral  column  has  been  opened  in 
several  instances,  and  the  compressing  focus  of  disease  removed. 

UNILATERAL  LESIONS  OF  THE  SPINAL  CORD. 

etiology. — A  unilateral  lesion  of  the  spinal  cord  is  one  that 
interrupts  the  functions  of  one-half  of  the  cord.     It  may  be  caused 


Uppermost     hy- 
peresthetic 


Anesthesia. 


Uppermost  liypeves- 
thetic  zone. 

Anesthesia  (in  conse- 
quence of  injury  to 
the  sensory  nerve- 
roots). 

Paralysis  of  motility 
and  of  the  vasomo- 
tor nerves  and  hy- 
peresthesia. 


Fig.  79.— Diagram  illustrating  the  symptoms  of  a  unilateral  lesion  of  the  left  half  of  the 

dorsal  cord. 


by  a  punctured  wound  of  the  spinal  cord,  although  it  may  develop 
also  in  connection  with  inflammation,  hemorrhage,  new-growths, 
and  compression  of  the  cord. 

Syinptoms  and  Diagnosis. — Unilateral  lesions  of  the  spinal 


572  NERVOUS  SYSTEM 

cord  give  rise  to  striking  and  readily  recognized  symptoms, 
namely,  paralysis  and  cutaneous  hyperesthesia  upon  the  side  of 
the  injury  and  anesthesia  upon  the  opposite  side.  Accordingly, 
spinal  hemiplegia  and  crossed  anesthesia  are  distinctive  of  a  uni- 
lateral lesion  of  the  spinal  cord.  Upon  the  paralyzed  side  the 
muscular  sense,  motor  power,  and  electromuscular  sensibility  are 
diminished.  Vasomotor  and  at  times  trophic  disturbances  also 
are  observed.  Reflex  irritability  is  unaltered  or  increased.  If 
the  cutaneous  hyperesthesia  is  traced  upward,  a  narrow  band  of 
cutaneous  anesthesia  will  be  detected  surrounding  the  trunk  upon 
the  paralyzed  side  from  the  middle  line  to  the  vertebral  column, 
and  referable  to  injury  of  posterior  nerve-roots.  Above  this  band 
is  a  hyperesthetic  zone  surrounding  the  trunk  entirely  (Fig.  79). 
The  distribution  of  the  phenomena  described  depends  upon  the 
seat  of  the  disease,  and  at  times  is  confined  to  the  lower  extremi- 
ties, while  at  other  times  it  involves  also  the  arms.  In  the  pres- 
ence of  disease  of  the  cervical  cord  symptoms  of  paralysis  of  the 
sympathetic  (contraction  of  the  pupils,  narrowing  of  the  palpebral 
fissure,  retraction  of  the  eyeballs,  redness  and  increased  heat  of 
one  side  of  the  face)  are  at  times  superadded.  Occasionally  paral- 
ysis of  the  bladder  is  present,  with  its  sequelae  and  the  develop- 
ment of  bed-sores.  ^Yith  a  lesion  that  progressively  extends  the 
clinical  picture  of  a  unilateral  lesion  may  gradually  disappear. 

The  symptoms  of  a  unilateral  lesion  of  the  spinal  cord  may  be  explained 
by  the  fact  that  a  portion  of  the  nerve-fibers  in  the  spinal  cord  are  uncrossed, 
while  others  are  crossed.  The  uncrossed  fibers  (motor,  vasomotor,  trophic, 
muscular  and  dynamic  sense,  and  muscular  sensibility)  must  therefore  be 
paralyzed  upon  the  side  of  the  lesion,  and  the  uncrossed  (sensory  fibers) 
upon  the  uninjured  side. 

The  progtiosis  and  the  treatment  will  depend  upon  the 
underlying  diseases. 

System- Diseases  of  the  Spinal  Cord. 
SINGLE  SYSTEM-DISEASES. 

TABES  DORSALIS    (POSTERIOR  SPINAL  SCXEROSIS; 
LOCOMOTOR  ATAXIA). 

Btiology. — Tabes  dorsalis  is  one  of  the  most  common,  and  at 
the  same  time  by  reason  of  its  incurable  character  one  of  the  most 
dreaded,  diseases  of  the  spinal  cord.  Most  cases  are  sequels  of 
syphilis.  Those  syphilitics  are  especially  liable  to  the  disease  in 
whom  the  original  disorder  was  not  thoroughly  treated.  Generally 
many  years  have  elapsed  before  the  symptoms  of  tabes  appear  in 
the  sequence  of  syphilis,  but  in  isolated  cases  I  have  observed  the 
symptoms  as  early  as  the  second  and  the  third  year.     Not  alone 


TABES  DOBSALIS  573 

acquired,  but  at  times  also  hereditary  syphilis  is  believed  to  give 
rise  to  tabes  dorsalis. 

Nothing  is  known  concerning  the  intimate  connection  between  tabes  dorsalis 
and  syphilis.  It  might,  for  instance,  be  supposed  that  syphilis  induces  a 
lessened  resistance  on  the  part  of  the  spinal  cord  toother  injurious  influ- 
ences, which  formerly  were  considered  as  the  actual  fundamental  causes; 
or  it  is  also  possiljle  that  poisons  (toxins)  of  the,  as  yet  unknown,  bacteria 
of  syphilis  cause  injury  to  the  tissues  of  the  cord.  Under  either  condition 
it  must  naturally  be  assumed  that  the  nerve-fibers  of  the  posterior  columns 
of  the  cord  or,  in  accordance  with  the  most  recent  views,  the  posterior 
spinal  nerve-roots  are  particularly  susceptible  to  the  injurious  influences 
of  the  syphilitic  poison. 

Although  syphilis  is  the  principal  cause  for  tabes  dorsalis,  it 
cannot  be  considered  as  the  sole  exciting  factor.  Other  infectious 
diseases  also  (typhoid  fever,  pneumonia,  diphtheria,  small-pox) 
may  act  as  causes.  The  occurrence  of  toxic  tabes  dorsalis  also  has 
been  recorded,  developing  after  intoxication  with  ergot  (ergotism) 
or  spoiled  maize  (pellagra)  and  excessive  indulgence  in  tobacco. 
At  times  tabes  dorsalis  develops  in  the  sequence  of  traumatism, 
particularly  concussion  of  the  spinal  column.  The  injurious  influ- 
ence of  cold  cannot  be  wholly  denied.  Upon  the  other  hand, 
nothing  definite  is  known  with  regard  to  the  etiologic  significance 
of  emotional  disturbances,  suppression  of  perspiration,  and  the  like. 
Tabes  dorsalis  occurs  most  frequently  between  the  thirtieth  and 
fortieth  years  of  life,  and  ten  times  more  commonly  in  men  than  in 
women. 

Anatomic  Alterations. — The  distinctive  anatomic  lesion  of 
tabes  dorsalis  consists  in  gray  degeneration  of  the  posterior  columns 
of  the  spinal  cord.  This  condition,  however,  appears  to  be  second- 
ary and  dependent  upon  disease  of  the  intervertebral  ganglia,  and, 
in  addition,  the  remainder  of  the  nervous  system  also  (cerebrum, 
cerebellum,  peripheral  nerves)  may  be  involved.  The  latter  fact 
explains  the  variability  in  the  clinical  picture.  After  opening  the 
dura  mater  gray  bands  are  often  visible  through  the  translucent 
pia  mater,  traversing  the  entire  length  of  the  spinal  cord  and 
diminishing  in  size  from  below  upward,  and  being  obscured  from 
view  only  when  the  pia  mater  upon  the  posterior  aspect  of  the 
cord  is  thickened,  and  hence  rendered  opaque.  The  related  por- 
tions of  the  spinal  cord  situated  between  the  posterior  nerve-roots 
and  the  posterior  columns  of  the  cord  frequently  are  remarkably 
small  and  generally  feel  indurated  (sclerotic).  On  transverse  sec- 
tion of  the  cord  the  posterior  columns  appear  gray  and  slightly 
translucent.  While  this  change  involves  the  entire  extent  of  the 
posterior  columns  in  the  lumbar  region,  including  the  columns  of 
Burdach  as  well  as  those  of  Goll,  toward  the  cervical  portion  it 
gradually  becomes  confined  to  the  postero-internal  or  columns  of 
Goll  (Fig.  80).  If  the  changes  in  the  spinal  cord  are  followed 
from  below  upward,  they  can  still  be  recognized  in  the  delicate 


574  NERVOUS  SYSTEM 

columns  bounding  the  fourth  ventricle,  and  at  times  they  can  be 
detected  also  in  the  peripheral  layers  of  the  pons  Varolii  and  the 
qiiadrigeniinal  bodies.  It  is  noteworthy  that  islets  of  medullated 
nerve-til)ers  always  persist  also  in  the  most  anterior  portions  of 
the  posterior  columns  in  the  lumbar  cord  close  to  the  gray  com- 
missure. The  difference  in  the  ajipearanee  of  the  anterior  and  the 
posterior  spinal  nerve-roots  is  striking,  for  while  the  former  gen- 
erally preserve  their  usual  size  and  natural,  medullary-white  ap- 
pearance, the  latter  are  thin,  gray,  and  almost  translucent. 

On  microscopic  examination  disappearance  of  the  nerve-fibers 
and  increase  of  the  neuroglia  are  found  in  the  diseased  posterior 
columns.  In  all  probability  the  atrophy  of  the  nerve-fibers  is  the 
primary  change,  to  which  the  increase  in  the  neuroglia  is  added 
secondarily.  In  the  hyperplastic  neuroglia,  which  in  advanced 
cases  acquires  a  fibrillated  ajjpearance,  isolated  fatty  granule-cells 
and  numerous  amyloid  bodies  are  not  rarely  present.  The  blood- 
vessels are  often  thickened  and  in  places  obliterated. 

Anatomic  alterations  are  encountered  also  in  the  columns  of  Clarke  and 
in  the  zone  of  Lissauer,  in  addition  to  the  jjosterior  columns  of  the  cord.  In 
the  columns  of  Clarke,  particularly  when  the  spinal  cord  is  stained  by 
Weigert's  hematoxylin-method,  the  disappearance  of  the  finer  nerve-fibers 
is  conspicuous,  while  the  ganglion-cells  appear  unaltered.  Also  in  the  zone 
of  Lissauer,  which  forms  the  peripheral  boundary  of  the  posterior  horns, 
atrophy  of  nerve-fibers  with  a  double  contour  has  taken  place.  Disappear- 
ance of  the  nerve-fibers,  and  in  lesser  degree  of  the  ganglion-cells,  occurs 
also  in  the  posterior  horns  of  the  spinal  cord. 

Examination  o^  \\\e  posterior  spinal  nerve-roots  discloses  atrophy 
and  disappearance  of  the  nerve-fibers  and  increase  of  the  con- 
nective tissue.  Atrophic  disappearance  of  the  ganglion-cells  and 
connective-tissue  proliferation  have  been  demonstrated  likewise  in 
the  intervertebral  ganglia,  although  the  alterations  in  the  posterior 
nerve-roots  not  rarely  predominate.  In  the  cerebral  cortex  and  in 
the  cerebellum  disappearance  of  nerve-fibers,  in  the  latter  also  that 
of  the  ganglion-cells  and  blood-vessels,  has  been  described.  De- 
generation and  disappearance  of  the  ganglion-cells  in  the  nuclei 
of  the  cerebral  nerves  is  noteworthy,  but  also  in  individual  cerebral 
nerves  themselves  degeneration  and  disappearance  of  nerve-fibers 
and  hyperplasia  of  the  connective-tissue  occur  in  their  trunks 
as  well  as  in  their  intramedullary  course.  Degeneration  and  dis- 
appearance of  nerve-fibers  in  the  peripheral  nerves  should  not  be 
overlooked.  These  alterations  occur  particularly  in  the  finer 
cutaneous  branches,  but  are  observed  also  in  the  larger  nerve- 
trunks. 

It  has  already  been  pointed  out  that  the  lesions  of  tabes  dorsalis  are 
dependent  upon  degenerative  and  not  inflammatory  alterations  in  the  nerve- 
fibers  of  the  spinal  cord.  It  appears  that  this  nerve-degeneration  does  not 
begin  primarily  in  the  spinal  cord,  but  originates  in  the  ganglion-cells  of 
the  intervertebral  ganglia.     As  is  well  known,  each  of  these  ganglion-cells 


TABES  DORSALIS  575 

gives  off  a  process,  whicli  soon  divides  into  two  branches,  one  of  which 
enters  a  peripheral  nerve  and  the  other  the  posterior  column  of  the  spinal 
cord.  As  a  result  of  morbid  activity  on  the  part  of  the  ganglion-cells  de- 
generation and  atrophy  take  place  in  the  branch  passing  to  the  spinal  cord, 
and  these  may  bring  about  the  anatomic  alterations  of  tabes  in  the  poste- 
rior columns.  In  harmony  with  this  view  is  the  fact  that  the  alterations 
become  more  restricted  to  the  columns  of  GoU  the  higher  up  in  the  cord 
they  are  situated,  as  fibers  from  the  nerve-roots  entering  the  lowermost 
portion  of  the  cord  become  gradually  displaced  toward  the  median  portion 
of  the  posterior  column  as  they  ascend.  Just  why  the  process  begins  in 
the  intervertebral  ganglia  of  the  lumbar  cord  has  not  yet  been  determined. 
Only  rarely  does  tabes  dorsalis  begin  in  the  cervical  cord,  when  the  disease 
may  be  confined  to  the  postero-external  (Burdach's)  columns.  The  condi- 
tion is  then  designated  cervical  tabes  dorsalis. 

Symptoms. — Among  the  symptoms  of  tabes  dorsalis  a  dis- 
tinction should  be  made  between  constant  (typical)  and  accidental 
symptoms.  The  former  particidarly  are  of  diagnostic  significance, 
and  they  alone  depend  upon  the  typical  seat  of  the  disease,  while 
the  accidental  symptoms  vary  accordingly  as  in  the  individual 
case  one  or  another  portion  of  the  nervous  system  becomes  in- 
volved. The  typical  symptoms  of  tabes  dorsalis  include  absence 
of  the  knee-jerks,  reflex  pupillary  immobility,  swajring  station,  and 
ataxic  gait.  Ahsence  of  the  knee-jerks,  also  known  as  Westphal's 
symptom,  is  one  of  the  earliest  and  most  constant  signs  of  tabes 
dorsalis,  and  there  should  always  be  some  hesitancy  in  making  a 
diagnosis  of  tabes  dorsalis  if  the  knee-jerks  are  preserved  unchanged. 
The  phenomenon  is  explained  by  the  fact  that  in  the  presence  of 
tabes  dorsalis  the  spinal  reflex  arc  is  interrupted.  This  interrup- 
tion was  formerly  believed  to  occur  in  the  posterior  columns  of  the 
spinal  cord  at  the  junction  of  the  dorsal  and  lumbar  portions,  within 
the  so-called  root-entrance  zone.  In  accordance  with  more  recent 
views  with  regard  to  the  development  of  tabes  dorsalis,  however, 
it  is  probable  that  the  interruption  of  the  spinal  reflex  arc  occurs 
in  the  degenerated  posterior  nerve-roots,  and  the  second,  third, 
and  fourth  lumbar  roots  are  those  especially  involved, 

I  have  been  able  to  demonstrate  by  clinical  observation  that  also  in 
cases  of  cervical  tabes  the  knee-jerks  may  be  absent  if  in  addition  to  the 
tabes  inflammation  of  the  crural  nerves  also  exists.  In  view  of  the  great 
significance  of  absence  of  the  knee-jerks  in  the  diagnosis  of  tabes  dorsalis  it 
is  exceedingly  important  to  avoid  all  sources  of  error  in  the  examination. 
The  extremity  to  be  examined  must  be  perf^ectly  relaxed,  and  is  either 
crossed  over  the  opposite  member  or  is  permitted  to  hang  witbout  constraint 
over  the  edge  of  a  chair  or  of  the  bed.  It  is  highly  useful  to  employ  the 
expedient  of  Jendrassik,  the  patient  during  the  examination  forcibly  pull- 
ing his  clasped  hands  apart  or  forcibly  squeezing  the  finger  of  the  exam- 
iner. By  means  of  such  devices  the  attention  of  the  patient  is  involuntarily 
diverted  from  the  examination  of  the  knee-jerk  and  the  member  is  relaxed 
unconsciously. 

The  suspicion  of  tabes  dorsalis  will  be  increased  if  in  addition 
to  absence  of  the  knee-jerks  there  is  also  reflex  pupillary  immobility. 
This  sign  is  known  also,  after  its  discoverer,  as  Robertson's  symp- 


576 


NERVOUS  SYSTEM 


torn.  This  is  developed  by  having  the  patient  look  toward  the 
sky  from  a  bright  window  while  light  is  excluded  from  the  eyes 
by  means  of  the  hands  held  before  the  eyes.     If  now  one  or  both 

hands    are    suddenly    re- 
moved   from    before   the 
eyes,   contraction    of    the 
Middle  of  the  olive  — ^BS^I^^^       pupils     on     exposure    to 

light  fails  to  take  place. 
The  size  of  the  pupils  re- 
mains the  same  in  the  dark 

Just  below  the  pyramidal £^^  and  on  exposure  to  light. 

decussation  W^P^Ss  n^,  ^  -n 

ihe  sensory  pupillary  re- 
action likewise  is  wanting ; 

Upper  cervical  portion  --  «^i  ^}]f^  i^'.^"  pricking  the  skin 

^w.^rirvnaf  clilatatiou  01  tlic  pupil  lails 

to  take  place.     The  reac- 

Cervical  enlargement fi^^^B  ^^^^    ^^    ^^^^    pupil    in    ac- 

commodation, however,  is 
preserved,  so  that  the  pu- 
Lower  cervical  portion  - B^^^B  pil''  become  dilated  in  dis- 

tant vision,  while  they  be- 

^B^zESJBM  come  contracted    in    near 

Lower  cervical  portion ^MwW^B  vision 

®0f  less  diagnostic  signifi- 
cance is  the  fact  that  the  pu- 
pils are  not  rarely  contracted 
^^^^  — spinal    mijosis — or    are   un- 

Mid-dorsal  portion ^S^m  equal. 

eWhen     the    eyes    are 
closed     the    body     sicays 
m  arkedly  —  Bracht-Rom- 

Commencementofthelum- .^Sf&  ^^^'9    Symptom.      This    not 

bar  enlargement           "    ^|^^^  rarely  becomes  so  marked 

that  the   patients   are   in 

Middle  of  the  lumbar  en- ^^  danger  of  foiling.     Often 

largement                    ^|^^  tlie    patient    has    noticed 

Mgf^  the    symptom    first   when 

Lowermost  lumbar  portion -^^  in  washing  the  face  he  has 

Fig.  80.— Transverse  sections  of  the  spinal  cord  been  compelled  tO  cloSC  hlS 

presenting  advanced  degeneration  of  the  posterior  eyCS 

columns  from  a  man  r>'2  years  old.  The  degenerated  ^       '  , 

areas  are  light,  as  they  appear  in  the  spinal  cord  AtaXlCL  IS  SO  Constant  a 

hardened  in  Mliller's  fluid.  ,  j?  j.   i         i  i* 

Natural  size;    from  transverse  sections  of  the  SymptOm  OT    taOCS  (lOrsallS 

spinal  cord  hardened  in  Midler's  fluid  (personal  +i,„f    fKo    rliooooo    line    olcrv 

observation,  Zurich  clinic).  ^"^^    l^''^    Clisease    lias    dlbO 

been  designated  progres- 
sive locomotor  ataxia.  It  can  be  recognized  in  walking  from  the 
fact  that  the  patient  holds  the  legs  far  apart  and  brings  the  feet  down 
upon  the  heels,  raising  the  extremities  unnecessarily  high,  and  at  the 


TABES  DORSALIS  577 

same  time  making  awkward  and  jerky  movements.  The  gait  is 
also  appropriately  characterized  as  sfringhalt-like.  If  the  patient 
be  requested  to  place  one  foot  in  advance  of  the  other  in  walking, 
or  if  he  make  an  attempt  to  walk  upon  a  crack  in  the  floor  or 
upon  a  chalk-line,  he  will  be  able  to  do  any  of  these  with  extreme 
difficulty  and  awkwardness,  if  at  all.  On  lying  in  bed  the  ataxia 
of  the  legs  will  be  shown  by  the  fact  that  in  elevating  one  of  the 
members  it  will  oscillate  to  and  fro  and  be  thrust  beyond  the  mid- 
dle line  toward  the  opposite  side.  All  ataxic  disturbances  are 
increased  in  the  dark,  when  the  patient  is  unable  to  guide  the 
movements  with  the  aid  of  vision.  Ataxic  movements  are  not 
uncommon  also  in  the  arms.  They  may  be  readily  recognized  if 
the  arms  are  widely  separated  when  the  eyes  are  closed  and  an 
attempt  is  made  to  bring  the  finger-tij)S  together.  In  ataxic 
patients  to-and-fro  movements  in  the  air  will  follow  for  some 
time  before  the  finger-tips  are  brought  in  contact. 

Much  discussion  has  taken  place  as  to  the  mode  of  origin  of  the  ataxia.  In 
our  opinion  the  view  of  Leyden  is  the  most  likely,  and  according  to  which 
the  ataxia  is  the  result  of  sensory  disturbances,  not  alone  cutaneous  sensi- 
bility, but  particularly  also  the  sensibility  of  the  deeper  structures  (muscles, 
tendons,  fascia,  joints),  being  affected. 

Possibly  disturbances  in  the  reflex  paths  in  the  spinal  cord  may  be 
operative.  Some  clinicians  have  attributed  the  ataxia  to  disease  of  deffnite 
spinal  tracts  supposed  to  possess  coordinative  activity  (lateral  cerebellar 
tracts),  but  nothing  is  known  with  regard  to  the  existence  of  such  tracts. 

The  typical  symptoms  of  tabes  clorsalis  thus  far  considered  de- 
velop slowly,  and  generally  with  prodromes.  The  latter  include 
with  especial  frequency  pain  in  the  course  of  one  or  both  sciatic 
nerves,  at  times  attacks  of  headache  and  vomiting,  vertigo,  and 
the  like. 

Among  the  accidental  symptoms  of  tabes  dorsalis  sensory  dis- 
turbances particularly  predominate,  and  this  can  be  readily  under- 
stood from  the  fact  that  the  morbid  process  develops  especially  in 
the  sensory  sections  of  the  cord  ;  but  motor,  trophic,  secretory,, 
and  vasomotor  manifestations,  together  with  visceral  disturbances, 
also  occur  not  at  all  rarely.  In  view  of  the  great  variability  in 
the  symptoms,  a  brief  consideration  of  the  most  important  of 
them  must  suffice.  Sensory  disturbances  are  scarcely  ever  wholly 
absent.  Often  the  patients  complain  of  paresthesise,  particularly 
the  crawling  of  ants,  prickling,  burning,  a  sense  of  cold,  and 
shooting  pains.  Often  complaint  is  made  of  a  painful  girdle- 
sense  about  the  trunk,  and  but  seldom  of  pain  in  the  vertebral 
column  itself.  Cutaneous  anesthesia  is  frequently  encountered,  at 
times  total,  at  other  times  partial.  The  anesthesia  is  generally 
most  pronounced  on  the  soles  of  the  feet,  and  progressively  dimin- 
ishes toward  the  trunk.  Often  the  patients  complain  of  not  feel- 
ing the  floor  beneath  their  feet,  and  in  M^alking  they  appreciate  a 

37 


578  NERVOUS  SYSTEM 

sensation  as  if  tliey  were  treacling  upon  wool,  or  were  going  about 
in  rubber  shoes  or  on  pigs'  bladders. 

At  times  poltjesthesia  is  observed,  the  application  of  a  needle  upon  tlie 
skin  being  felt  as  a  multiple  irritation.  Quite  often  the  conduction  of  sen- 
sory stimuli  is  retarded,  at  times  more  than  ten  seconds  elapsing  before  the 
patient  indicates  that  he  feels  the  prick  of  a  needle.  Duplicate  sensations 
are  occasionally  observed.  Either  a  single  needle-prick  is  felt  by  the  pa- 
tient at  first  as  touch  and  after  some  time  as  pain,  or  at  first  slight  and  after 
a  few  seconds  a  more  marked  perception  of  pain  occurs.  Not  rarely  the 
sensory  impression  persists  for  a  long  time. 

Frequently  disturbances  of  the  muscular  sense  are  demonstrable, 
and  when  the  eyes  are  closed  the  patient  is  incapable  of  deter- 
mining which  of  the  two  members  placed  at  different  levels  is  the 
higher,  which  is  the  more  flexed,  and  the  like.  Paralysis  plays 
a  rather  subordinate  part  in  the  clinical  picture  of  tabes  dorsalis. 
At  any  rate,  it  has  nothing  to  do  with  the  occurrence  of  the  ataxia, 
for  in  spite  of  marked  ataxia  the  motor  power  in  the  lower  ex- 
tremities may  be  unaltered.  At  times  paralysis  in  the  distribution 
of  certain  nerves  (peroneal,  radial)  appears  early.  This  has  been 
attributed  to  periplieral  neuritis,  which  may  gradually  subside  and 
undergo  perfect  recovery. 

Muscular  contractures  and  muscular  twitching  are  less  common  manifesta- 
tions. 

Among  trophic  disorders  the  tabic  articular  changes  especially 
have  long  attracted  attention.  The  large  joints  are  attacked  with 
especial  frequency,  particularly  the  knee-joints.  As  a  rule,  the 
joints  become  enlarged,  and  they  are  at  the  same  time  but  little,  if 
at  all,  tender  to  touch,  and  after  the  articular  enlargement  has  sub- 
sided deformity  and  ankylosis  may  persist  because  the  articular 
extremities  are  greatly  distorted. 

Among  other  trophic  disorders  in  the  course  of  tabes  dorsalis  there  may 
be  mentioned  abnormal  fragility  of  the  bones,  an  ujidue  tendency  to  laceration 
on  the  part  of  certain  tendons,  particularly  the  Achilles  tendon,  hemiatrophy 
of  the  tongue,  perforating  ulcer  of  the  foot,  herpes  zoster,  thickening  af  the  nails, 
loss  of  the  teeth,  the  nails,  and  the  hair,  etc. 

Vasomotor  and  secretory  disorders  are  revealed  by  unusual  red- 
ness and  heat  of  the  skin,  by  hyperidrosis,  increased  secretion  of 
saliva  and  of  tears,  and  the  like.  Among  the  visceral  disturbances 
of  tabes  dorsalis  the  visceral  crises  deserve  first  mention.  These 
consist  in  sudden  attacks  of  pain  and  functional  disturbance  in 
certain  organs.  Gastric  crises  are  the  most  common  and  the  best 
known.  These  consist  in  attacks  of  severe  epigastric  pain  with 
profuse  vomiting,  which  may  persist  for  days,  and  is  at  times 
attended  with  an  excess  of  hydrochloric  acid.  If  the  attacks  are 
repeated  in  quick  succession,  the  patient  may  become  exhausted  in 
an  alarming  degree.  Often  such  patients  are  treated  for  years  for 
chronic  gastric  catarfh,  and  are  sent  each  summer  to  health-resorts 


TABES  DORSALIS  579 

before  the  real  nature  of  the  gastric  disorder  is  recognized.  At 
times  gastric  crises  deviate  from  the  typical  picture  described  in 
so  far  as  they  are  attended  either  with  severe  epigastric  pain  alone 
or  only  with  profuse  vomiting  without  such  pain. 

Among  other  visceral  crises  intestinal  crises  may  be  mentioned.  These 
are  attended  with  paroxysmal  attacks  of  diarrhea,  usually  accompanied  by 
colic.  Rectal  crises  are  attended  with  burning  pain  in  the  rectum.  Renal 
crises  suggest  the  clinical  picture  of  renal  colic,  and  are  attended  with  severe 
pain  in  the  loin,  but  they  are  generally  unattended  with  albuminuria  and 
hematuria.  Laryngeal  crises  are  characterized  by  attacks  of  cough  and 
dyspnea  resembling  whooping-cough  or  laryngismus  stridulus.  Pharyngeal, 
bronchial,  cardiac,  clitoral,  and  urethral  crises  also  have  been  described. 

Among  other  visceral  manifestations  ocular  changes  deserve 
first  place  on  account  of  their  diagnostic  importance.  Not  rarely 
optic  atrophy  develops,  and  may  give  rise  to  gradual  blindness.  At 
times  blindness  occurs  early,  so  that  the  patients  must  bear  the 
burden  of  their  disease  for  many  years  in  a  blind  state.  Paral- 
ysis of  the  ocular  muscles  is  often  present,  and  it  may  disappear 
after  a  time,  being  probably  more  frequently  dependent  upon 
peripheral  neuritis  than  upon  disease  of  the  nuclei  of  the  nerves. 
Paralysis  of  the  laryngeal  muscles  also  is  not  rarely  observed  in  the 
course  of  tabes  dorsalis.  The  statement  that  tabic  patients  present 
valvular  lesions  of  the  heart  with  especial  frequency  I  am  unable 
to  confirm  from  personal  observation.  Frequently,  and  at  times 
early,  symptoms  of  paralysis  of  the  bladder  occur.  These  may 
appear  and  disappear  repeatedly  in  the  course  of  the  disease. 
Eventually  they  may  persist,  and  then  are  attended  with  the 
dangers  of  urinary  infection  and  of  bed-sores.  In  men  impotence 
not  rarely  occurs  early.  Women,  however,  may,  in  spite  of  ad- 
vanced tabes  dorsalis,  conceive  and  bear  children  in  the  usual 
manner. 

The  course  of  tabes  dorsalis  is  chronic,  and  the  disease  often 
extends  over  many  years.  Attempts  have  been  made  to  distin- 
guish several  stages  of  the  disease,  although  all  such  divisions 
are  somewhat  artificial  and  of  slight  practical  value.  Should  the 
ataxia  in  the  lower  extremities  become  excessive,  the  patients  will 
be  unable  to  move  about  alone,  even  with  the  aid  of  a  cane,  and 
will  be  compelled  to  remain  constantly  in  bed.  At  times  in  at- 
tempts at  walking  the  patient  may  stumble  over  his  own  feet  and 
fall  to  the  ground.  After  the  patient  has  been  confined  to  bed  for 
a  long  time  atrophy  of  the  muscles  of  the  lower  extremities 
develops  from  disuse,  with  a  condition  of  weakness  and  the  devel- 
opment of  muscular  contractures.  At  times  apoplectiform  attacks 
occur  with  hemiplegia,  the  latter  disappearing ;  but  if  dependent 
upon  thrombosis  of  cerebral  arteries  the  paralysis  may  persist.  The 
mental  state  of  the  patient  is  often  stated  to  be  an  abnormally  ciieer- 
ful  one.  I  should  rather  describe  it  as  one  of  fatalistic  resignation. 
Psychic  disturbances  occur,  and  predominate  from  the  outset  in 


580  NERVOUS  SYSTEM 

cases  in  wliicli  tabes  dorsalis  occurs  in  connection  with  progressive 
paralysis  of  the  insane.  Death  takes  pkice  in  consequence  either 
of  accidental  disease  (pneumonia,  puhiionary  tuberculosis)  or  of 
progressive  exhaustion,  or  of  urinary  infection  or  septicemia  ;  at 
[times  also  with  the  occurrence  of  a  soporose  state  of  sudden  onset. 
I  Diagnosis. — In  the  diagnosis  of  tabes  dorsalis  reliance  should 
be  placed  upon  the  four  typical  symptoms  :  Absence  of  the  knee- 
jerks,  reflex  pupillary  ihimobility,  unsteadiness  in  station,  and 
'ataxia.  Confusion  with  peripheral  pseudotabes  may  readily  occur 
'when  this  condition  develops  as  a  result  of  polyneuritis.  Peripheral 
pseudotabes  occurs  with  particular  frequency  and  distinctness  in 
connection  with  alcoholic,  diabetic,  postdiphtheric,  and  toxic  poly- 
neuritis. Although  the  reaction  of  the  pupils  may  be  exceedingly 
sluggish  in  the  presence  of  polyneuritis,  reflex  jiupillary  immo- 
bility scarcely  ever  occurs,  and  the  presence  of  the  latter,  there- 
fore, is  always  indicative  of  tabes  dorsalis.  Tabes  dorsalis  Mill 
scarcely  be  confounded  with  cerebellar  ataxia,  because  the  knee- 
jerks  are  preserved  in  the  presence  of  cerebellar  disease.  Heredi- 
tary ataxia  often  develops  during  childhood,  and  is  attended  with 
nystagmus  and  articulatory  disturbances. 

Prognosis. — The  prognosis  of  tabes  dorsalis  is  unfavorable 
with  regard  to  recovery,  although  life  does  not  appear  to  be  im- 
mediately threatened,  and  if  the  patient  does  not  come  under  pro- 
fessional observation  too  late  material  improvement  may  at  times 
be  brought  about. 

Treatment. — As  syphilis  is  the  cause  of  tabes  dorsalis  in  the 
majority  of  cases,  it  might  be  supposed  that  in  such  cases  causal 
therapy  with  mercurial  inunctions  (5.0—75  grains — daily)  and 
potassium  iodid  (5.0  :  200 — 75  grains  :  6  J  fluidounces  ;  15  c.c. — 
1  tablespoonful — thrice  daily)  would  yield  good  results.  Too 
much,  however,  should  not  be  expected  in  this  connection.  Im- 
provement fails  to  take  place  in  the  majority  of  cases,  or  under 
the  most  favorable  circumstances  it  is  but  slight.  This  is  prob- 
ably due  to  the  fact  that  the  patients  generally  come  under  pro- 
fessional observation  too  late,  and  that  under  the  most  favorable 
circumstances  preparations  of  mercury  and  of  iodin  are  capable  only 
of  arresting  the  morbid  process  or  checking  the  course  of  the  dis- 
ease, and  not  of  effecting  recovery.  Such  nerve-fibers  as  are 
already  degenerated  are  lost  forever.  Nevertheless,  antisyphilitic 
treatment  should  always  be  advised,  and  it  should  even  be  repeated 
from  time  to  time.  Among  internal  remedies,  I  have  in  a  number 
of  cases  observed  surprising  results  from  the  use  of  ftUver  nitrate, 
while  the  remaining  large  number  of  nervines  have  been  dis- 
appointing : 

R   Silver  nitrate,  0.3  (4J  grains) ; 

Aluminum  hydrate,  sufficient  to  make  30  pills. 
Dose :  1  pill  thrice  daily. 


SPASTIC  SPINAL  PARALYSIS  581 

Gymnastic  exercises  with  tlie  lower  extremities,  and  if  neces- 
sary also  with  the  upper  extremities,  are  to  be  warmly  recom- 
mended. Tlie  patient  is,  for  instance,  instructed  to  walk  several 
times  daily  upon  certain  lines  and  figures,  and  as  a  result  the 
ataxic  disturbances  not  rarely  subside,  and  the  power  of  locomo- 
tion is  greatly  improved.  I  have  in  a  number  of  cases  also 
observed  material  improvement  in  the  power  of  locomotion  as  a 
result  of  treatment  by  suspension.  Not  much  can  be  accomplished 
by  courses  of  treatment  at  the  baths  (saline,  sulphurous,  indiiferent 
baths,  courses  of  treatment  with  cold  water).  Well-to-do  patients 
may  be  advised  to  pass  the  winter  in  mild  climatic  resorts 
(Riviera),  in  order  to  be  in  the  open  air  as  much  as  possible.  A 
sea-voyage  also  may  be  recommended.  For  neuralgias,  antipyrin 
(1.0 — 15  grains — thrice  daily)  or  phenacetin  (1.0 — 15  grains — 
thrice  daily)  may  be  employed.  At  times  subcutaneous  injections 
of  morphin  must  be  resorted  to.  These  constitute  also  the  most 
reliable  means  of  relieving  severe  visceral  crises.  The  faradic 
and  the  galvanie  current  will  not  aiford  any  material  relief. 


SPASTIC   SPINAL   PARALYSIS. 

l^tiology  and  Anatomic  Alterations. — Disease  of  the  lat- 
eral pyramidal  tracts  is  believed  to  be  the  cause  of  spastic  spinal 
paralysis.  Although  the  clinical  picture  of  spastic  spinal  paral- 
ysis is  by  no  means  rare,  it  has  been  shown  that  it  generally 
results  in  consequence  of  other  diseases  of  the  spinal  cord,  while 
it  occurs  with  exceeding  rarity  as  an  independent  disorder.  It  is 
encountered  with  especial  frequency  in  connection  with  myelitis, 
spinal  pressure-paralysis,  multiple  cerebrospinal  sclerosis,  com- 
bined system-disease  of  the  spinal  cord,  and  syphilitic  spinal 
paralysis.  Spastic  spinal  paralysis  develops  not  rarely  in  children 
when  in  consequence  of  protracted  or  artificial  labor,  or  during 
teething,  or  after  infectious  diseases  cerebral  paralysis  occurs,  at 
times  in  the  form  of  monoplegia,  at  other  times  of  hemiplegia, 
and  at  still  other  times  of  paraplegia.  The  condition  is  known 
also  as  spastic  rigidity  of  the  extremities  or  Little's  disease. 
Exposure  to  cold,  infectious  diseases,  and  alcoholism  are  mentioned 
as  causes  of  independent  spastic  spinal  paralysis,  although  actually 
little  of  a  definite  nature  is  known  in  this  connection. 

Symptoms,  Diagnosis,  and  Prognosis. — The  symptoms 
begin  generally  in  tlie  lower  extremities.  Muscular  weakness  de- 
velops, and  may  progress  to  marked  paralysis.  At  the  same  time 
muscular  contractures  appear,  jjarticularly  in  the  extensors  and  the 
adductors  of  the  thigh  and  in  the  flexors  of  the  foot.  The  gait 
assumes  the  character  that  has  been  designated  spastic-paretic. 
The  tendon-reflexes  are  abnormally  increased.     Sensibility  and  the 


582  NERVOUS  SYSTEM 

functions  of  the  bladder  and  the  rectum,  however,  remain  undis- 
turbed. 

The  spudk-pa.rctic  gait  is  characterized  by  a  peculiar  rigidity 
of  the  lower  extremities,  which  in  talking  are  applied  firmly  to 
the  o-round  like  stilts.  The  extremities  are  scarcely  flexed  at  the 
hip  and  the  knee,  and  the  thighs  can  be  moved  in  front  of  each 
other  only  with  great  difficulty  on  account  of  adductor-C(>ntrac- 
ture,  so  that  often  the  pelvis  is  greatly  rotated  in  walking.  Con- 
tractures of  the  muscles  of  the  calf  often  give  rise  to  pes  equinus, 
so  that  the  patient  in  walking  first  applies  the  toes  to  the  ground, 
and  in  consequence  of  exaggeration  of  the  tendon-reflexes  the  legs 
are  set  into  tremulous  and  agitated  movement.  If  the  morbid 
process  advances,  contractures  gradually  develop  in  the  flexors  of 
the  thigh  and  the  leg,  and  these  render  walking  wholly  impos- 
sible. 

Exaggeration  of  the  knee-jerks  will  be  manifested  by  marked 
and  persistent  contraction  in  the  extensor  of  the  thigh  after  even  a 
slight  blow  with  the  plexor.  At  times  reflex  muscular  twitching 
occurs  as  well  in  members  not  percussed.  Ankle-clonus  also  is  ex- 
aggerated ;  and  if  with  the  leg  extended  dorsal  flexion  of  the  foot 
is  practised  suddenly,  active  flexion  and  extension  of  the  foot  take 
place,  which  not  rarely  can  be  prevented  intentionally  by  rapid 
dorsal  flexion  of  the  great  toe.^  If  the  arms  are  involved,  active 
reflex  muscular  contraction  will  follow  percussion  of  the  extensor 
tendons  of  the  forearm  or  the  tendon  of  the  triceps.  The  peri- 
osteal reflexes  also  are  abnormally  increased. 

The  duration  and  the  curability  of  the  symptoms  depend  upon 
the  nature  of  the  primary  disorder.  In  cases  of  independent 
spinal  paralysis  complete  recovery  has  been  observed  at  times  in 
the  course  of  a  few  weeks. 

Treatment. — Treatment  should  be  directed,  in  the  first  place, 
to  the  primary  disorder — causal  therapy.  In  cases  of  independent 
spastic  spinal  paralysis  hot  baths,  nervines,  electricity,  and  mas- 
sage have  been  employed. 

DISEASE   OF   THE    GANGLION-CELLS    OF   THE   AN- 
TERIOR HORNS  r ANTERIOR  POLIOMYELITIS). 

Poliomyelitis  indicates  only  inflammation  in  the  anterior  horns 
of  the  spinal  cord,  btit  the  structures  upon  which  the  characteristic 
features  of  the  clinical  picture  depend  are  the  multipolar,  motor- 
trophic  ganglion-cells  in  the  anterior  horns,  whose  destruction  is 
followed  by  flaccid  paralysis  of  the  related  muscles,  rapidly  de- 
veloping degenerative  muscular  cdrophy,  degenerative  electric  reac- 
tion in  the  diseased  nerves  and  muscles,  abolition  of  the  reflexes, 

^  Irritation  of  the  sole  of  the  foot  induces  extension  of  the  great  toe  and  per- 
haps also  of  the  remaining  toes. — A.  A.  E. 


DISEASE  OF  GANGLION-CELLS  OF  ANTERIOR  HORNS    583 

with  preservation  of  cutaneous  sensibility  and  of  the  functions  of  the 
bladder  and  the  rectum.  In  accordance  with  the  course  of  the  dis- 
ease and  the  age  of  the  patient,  several  clinical  varieties  may  be 
distinguished,  namely  :  acute  spinal  paralysis  of  childhood  ;  acute, 
subacute,  and  chronic  spinal  paralysis  of  adults;  spinal  progres- 
sive muscular  atrophy. 

ACUTE  SPINAL  PARALYSIS  OF  CHILDHOOD. 
l^tiology. — Acute  spinal  paralysis  of  childhood  is  one  of  the 
most  common  diseases  of  this  period  of  life,  and  experience  has  shown 
that  it  is  more  common  in  boys  than  in  girls,  and  that  it  occurs 
especially  at  the  period  of  dentition,  and  from  that  time  on  to  the 
fourth  year  of  life.  There  is  a  tendency  at  the  present  day,  and 
not  without  reason,  to  assume  the  occurrence  of  infection  in  many 
cases,  as  in  the  first  place  the  entire  course  of  the  disorder  corre- 
sponds in  many  respects  with  that  of  an  acute  infectious  disease, 
and  in  addition  the  disease  occurs  at  times  in  endemic  or  epidemic 
distribution.  Besides,  exposure  to  cold,  traumatism,  fright,  and 
emotional  disturbances  generally,  difficult  dentition,  and  antecedent 
infectious  disease  are  assumed  to  be  causative  factors. 

Anatomic  Alterations. — The  alterations  of  acute  spinal 
paralysis  of  childhood  arise  from  the  blood-vessels  of  the  anterior 
horns.  These  are  dilated  and  extremely  tortuous,  ruptured  in 
places,  and  presenting  in  their  adventitial  lymph-sheaths,  as  well 
as  outside  of  these,  accumulations  of  round  cells.  The  ganglion- 
cells  are  swollen,  plump,  in  part  deprived  of  their  processes,  and 
they  are  likewise  surrounded  by  round  cells.  In  the  fresh  state 
the  inflammatory  area  presents  a  blood-red  and  softened  appear- 
ance. Subsequently  it  becomes  converted  into  a  sort  of  cicatricial, 
sclerotic,  and  contracted  tissue,  which  contains  but  a  few,  if  any, 
ganglion-cells,  and  may  persist  throughout  the  rest  of  life.  Even 
after  the  lapse  of  many  years  the  disease-focus  is  recognizable 
from  the  contraction  and  diminution  in  size  of  the  anterior  horn. 
The  disease  is  at  times  unilateral  and  at  other  times  bilateral,  and 
it  may  appear  as  a  small,  circumscribed  focus  or  as  an  extensive 
process,  or  as  a  number  of  disseminated  foci.  In  the  anterior 
nerve-roots  related  to  the  foci  of  disease  degeneration  and  disap- 
pearance of  nerve-fibers  are  found — alterations  that  may  be  traced 
in  the  peripheral  nerves  to  the  muscles.  In  the  muscles  atrophy 
of  muscular  fibers  takes  place,  with  increase  in  the  connective 
tissue,  the  latter  being  not  rarely  well  supplied  with  fat-cells.  The 
atrophic  muscular  fibers  are  characterized  by  an  abundance  of 
sarcolemma-nuclei,  and  often  also  by  unusual  distinctness  of  their 
transverse  striation.  Other  muscle-fibers  exhibit  fibrillation  and 
vitreous  degeneration.  In  addition  to  atrophic  muscle-fibers,  here 
and  there  also  hypertrophic  fibers  are  present,  which  not  rarely 
contain  vacuoles  and  accumulations  of  nuclei. 


584  NERVOUS  SYSTEM 

Symptoms. — Should  acute  spiual  paralysis  of  childhood  de- 
velop like  au  acute  infectious  disease,  it  begins  suddenly,  or,  after 
a  sense  of  general  malaise  has  been  present  for  a  few  days,  with 
high  fever,  delirium,  stupor,  general  clonic  spasm  ;  and  if,  after  the 
lapse  of  some  hours  or  a  few  days,  consciousness  returns  and  the 
fever  has  disappeared,  the  paralysis  is  noticed.  In  other  instances 
naturally  the  paralysis  has  developed  quite  insidiously  and  without 
antecedent  febrile  prodromes.  The  child  may  have  appeared 
perfectly  well  on  retiring,  and  awakes  on  the  following  morning 
paralyzed.  Under  such  conditions  there  is  great  danger  that  the 
paralysis  will  be  overlooked  by  the  family  for  some  time,  and 
possibly  it  is  discovered  only  by  accident.  Most  commonly  in 
cases  of  spinal  paralysis  of  childhood  the  lower  extremity,  and 
with  especial  frequency  the  left,  is  the  seat  of  the  paralysis,  and 
even  in  the  leg  the  condition  is  often  one  of  partial  paralysis  only, 
involving  preferably  the  distribution  of  the  peroneal  nerve.  In 
other  instances,  in  accordance  Avith  the  seat  of  the  focus  of  inflam- 
mation, there  may  be  paraplegia  of  the  lower  or  of  the  upper  ex- 
tremities, total  paraplegia,  hemiplegia,  or  crossed  hemiplegia.  In- 
volvement of  the  cerebral  nerves,  as,  for  instance,  the  facial  nerve, 
is  extremely  rare. 

At  times  a  portion  of  the  paralysis  subsides  in  the  course  of 
a  few  days — so-called  temporary  para/i/sis — a  manifestation  that 
is  dependent  upon  the  fact  that  some  ganglion-cells  are  not  de- 
stroyed, but  are  unduly  compressed,  so  that  they  resume  their 
functional  activity  after  absorption  of  inflammatory  products  has 
taken  place  and  the  excessive  pressure  has  been  removed.  It 
does  occasionally  happen  that  the  paralysis  wholly  disappears,  but 
this  is  exceedingly  rare,  and  those  parts  that  are  paralyzed  after 
the  lapse  of  four  weeks,  experience  has  shown,  remain  always 
paralyzed.  The  muscular  paralysis  is  invariably  of  flaccid  type, 
so  that  the  paralyzed  members  can  be  moved  passively  to  and  fro 
without  resistance.  Toward  the  end  of  the  first  week  emaciation 
becomes  noticeable  in  the  paralyzed  muscles,  and  this  increases 
from  week  to  week ;  it  appears  and  advances  too  rapidly  to  be 
explained  as  the  result  of  atrophy  from  disuse.  In  conjunction 
with  progressive  wasting  degenerative  electric  reaction  in  the 
paralvzed  muscles  and  the  related  nerves  and  increased  meclianical 
muscular  irritability  occur. 

Sensory  disturbances  are  wanting  as  a  rule.  At  times  para- 
lyzed nerves  and  muscles  are  sensitive  to  pressure.  Older  chil- 
dren occasionally  complain  also  of  a  sense  of  dragging  and  even 
of  painful  sensations  along  the  vertebral  column  at  the  onset 
of  the  disease.  As  the  spinal  reflex  arc  has  been  interrupted 
by  the  disease  of  the  ganglion-cells  of  the  anterior  horn,  it  will 
be  understood  that  all  reflex  movement  will  be  wanting  in  the 
paralyzed  parts.     Vasomotor  disturbances  are  frequently  present. 


DISEASE  OF  GANGLION-CELLS  OF  ANTERIOR  HORNS    585 

The  skin  of  the  paralyzed  member  presents  a  cyanotic  appear- 
ance and  generally  feels  cool.  Trophic  disturbances  likewise  have 
been  observed.  The  skin  of  the  paralyzed  parts  frequently  pre- 
sents an  unusually  thick  layer  of  adipose  tissue,  which  in  part 
conceals  the  marked  wasting  of  the  paralyzed  muscles.  Also,  in 
the  muscles  themselves  active  deposition  of  fat  takes  place,  Mdiich 
in  part  neutralizes  the  loss  of  actual  muscular  tissue.  It  is  note- 
worthy also  that  the  bones  are  notably  retarded  in  growth,  are 
thin  and  unusually  brittle,  and  when  the  child  has  grown  up  the 
paralyzed  member  at  times  forms  only  a  small  appendage.  Even 
tendons,  fascise,  and  blood-vessels  in  the  distribution  of  the  mus- 
cular paralysis  fail  to  grow  normally. 

The  functional  activity  of  the  bladder  and  the  rectum  does  not 
suffer.  Muscular  contractures  develop  frequently  in  the  course  of 
the  disease,  and  they  may  give  rise  to  marked  deformities  and  in- 
terference with  the  function  of  the  paralyzed  members.  Abnormal 
demands  upon  the  healthy  muscles,  the  weight  of  the  bed-cloth- 
ing, and  similar  circumstances  are  the  causative  factors  for  such 
muscular  shortening.  Under  such  conditions  club-foot  of  any 
variety  may  develop,  as  well  as  spinal  curvature,  flail-joint,  and 
the  like.  Poor  patients  may  pass  through  life  as  cripples,  and 
utilize  their  infirmity  as  a  means  for  exciting  the  sympathy  of 
those  in  better  circumstances.  They  often  devise  ingenious  appa- 
ratus for  the  purpose  of  neutralizing  the  functional  disturbance  in 
the  legs  or  the  arms,  as,  for  instance,  supports,  upon  which  they 
can  move  about,  rolling  vehicles,  and  the  like. 

The  course  of  the  disease  is  chronic,  and  the  patients  often  attain 
advanced  age.  Occasionally  symptoms  of  spinal  progressive  mus- 
cular atrophy  develop  at  a  later  period.  Other  patients  become 
idiotic  and  epileptic.  Some  are  greatly  burdened  by  excessive 
obesity,  to  which  many  patients  are  predisposed  by  sedentary  pur- 
suits and  deficient  activity. 

DiagtiosiS. — The  recognition  of  acute  spinal  paralysis  of 
childhood  is  easy.  The  disease  might  most  readily  be  confounded 
with  acute  polyneuritis,  but  with  the  latter  nerves  and  muscles  are 
generally  sensitive  to  pressure,  and,  in  addition,  various  sensory 
disturbances  are  present.  Parturitional  or  obstetric  palsies  (p.  499) 
have  existed  from  birth,  and  in  cases  of  spastic  spinal  paralysis 
the  tendon-reflexes  are  exaggerated. 

Prognosis. — Although,  as  a  rule,  the  disorder  is  unattended 
Mnth  danger  to  life,  nevertheless  the  prognostic  outlook  is  not 
favorable,  because  the  paralysis  does  not  subside  and  nmscular 
contractures  and  deficient  growth  of  the  bones  increase  the  in- 
firmity. 

Treatment. — The  treatment  varies  with  the  stage  of  the  dis- 
ease. During  the  prodromal  febrile  period  a  hot  bath  (28°  R. — 
35°  C. — 95°  F.  for  fifteen  minutes)  should  be  given,  an  ice-bag 


586  NERVOUS  SYSTEM 

applied  to  the  head,  and,  if  the  child  can  swallow,  phenacetin 
(0.8 — 4^  grains — twice  daily)  or  antipyrin  (0.3 — 4^  grains — twice 
daily)  administered  internally.  The  application  of  an  ice-bag  to 
the  vertebral  column  may  also  be  advised.  For  the  paralysis, 
massage  should  be  practised  daily.  At  the  same  time  varied 
passive  movements  of  the  joints  should  not  be  omitted,  in  order 
to  prevent  as  much  as  possible  the  development  of  contractures. 
The  application  of  electricity  to  the  spinal  cord  and  to  the  para- 
lyzed muscles  will  be  attended  with  as  little  success  as  the  internal 
administration  of  the  various  nervines.  Little  also  is  to  be  ex- 
pected from  baths  (saline  or  sulphurous  or  indifferent  thermal 
baths).  On  the  other  hand,  surgical  and  orthopedic  measures  may 
yield  good  results  in  the  presence  of  contractures. 


ACUTE,  SUBACUTE,  AND  CHRONIC  INFLAMMATION  OF  THE 
GANGLION-CELLS  OF  THE  ANTERIOR  HORNS  IN  ADULTS 
(ACUTE,  SUBACUTE,  AND  CHRONIC  POLIOMYELITIS  OF 
ADULTS). 

Acute  anterior  poliomyelitis  of  adults  in  its  clinical  course  most 
closely  resembles  acute  spinal  paralysis  of  childhood.  It  is,  on 
the  whole,  a  rare  disease,  which  experience  has  shown  is  more 
common  in  men  than  in  w^omen,  and  which  generally  occurs  before 
the  thirtieth  year  of  life.  It  has  been  observed  in  the  sequence  of 
infectious  diseases  (puerperal  fever,  gonorrhea).  I  have  had  under 
observation  individuals  in  whom  the  affection  gave  the  impression 
of  being  an  independent  infectious  disease.  Exposure  to  cold,  ti-au- 
matism,  over-exertion,  and  alcoholic  and  venereal  excesses  also  are 
capable  of  acting  as  causes.  The  disease  begins  with  feb7'ile  pro- 
dromes. Often  a  chill  occurs  at  the  beginning,  followed  by  high 
fever,  stupor,  and  delirium — a  condition  that  often  persists  for 
one  or  two  weeks.  Clonic  convulsions  are,  however,  commonly 
absent,  perhaps  because  the  motor  cortical  centers  are  more  resist- 
ant in  adults  than  in  children.  3Iuscular  jxirali/sis  then  generally 
sets  in  suddenly,  and,  as  in  cases  of  spinal  paralysis  of  children,  it 
is  of  flaccid  type,  is  attended  with  rapid  degenerative  wasting, 
degenerative  electric  reaction,  and  increased  mechanical  irrita- 
bility, with  loss  of  the  cutaneous  and  tendinous  reflexes,  while 
sensibility  and  the  functions  of  the  bladder  and  the  rectum  exhibit 
no  derangement.  At  times  the  paralyzed  nerves  and  muscles  are 
sensitive  to  pressure,  and  the  overlying  skin  is  often  mottled  blue 
and  feels  cold.  Further,  the  paralysis  at  times  subsides  in  part — 
temporary  paralysis — and  in  individual  rare  cases  the  paralysis 
has  disappeared  entirely.  The  paralysis  disappears  especially 
from  such  muscles  as  exhibit  no  degenerative  electric  reaction. 
The  distribution  of  the  paralysis  varies,  as  with  spinal  paralysis  of 
childhood,  between  monoplegia,  paraplegia,  hemiplegia,  and  paral- 


DISEASE  OF  GANQLION-CELLS  OF  ANTERIOR  HORNS    587 

ysis  of  individual  neuromuscular  areas.  Cerebral  nerves  are  but 
rarely  affected.  After  the  paralysis  has  existed  for  some  time 
muscular  contractures  may  develop.  Disturbances  in  growth  of 
bones,  tendons,  fasciae,  and  blood-vessels  do  not  occur,  because  the 
members  of  the  patient  are  fully  developed. 

The  diagnosis,  the  prognosis,  and  the  treatment  are  the 
same  as  for  acute  spinal  paralysis  of  childhood. 

Subacute  and  chronic  anterior  poliomyelitis  of  adults  is  due  to 
the  same  causes  as  the  acute  variety,  is  likewise  one  of  the  less 
common  diseases  of  the  spinal  cord,  and  develops  generally  between 
the  thirtieth  and  the  fiftieth  year  of  life.  The  disorder  sets  in  in- 
sidiously without  antecedent  febrile  manifestation,  most  commonly 
in  the  extensors  of  the  leg,  tlien  slowly  invading  the  muscles  of 
the  trunk  and  the  arms,  and  even  those  supplied  by  the  cerebral 
nerves.  Less  commonly  the  onset  is  marked  by  paralysis  in  the 
arms,  and  this  may  then  extend  to  the  legs.  The  disease  is  pro- 
gressive in  course,  although  it  may  happen  that  the  paralysis  sub- 
sides spontaneously  in  part  or  at  times  even  entirely — temporary 
paralysis ;  although,  on  the  other  hand,  danger  exists  that  the  dis- 
ease may  involve  cerebral  nerves  (hypoglossal,  vago-accessory, 
glossopharyngeal),  and  death  resnlt  from  inspiration-pneumonia 
or  paralysis  of  respiration  or  of  cardiac  action.  Accordingly  as 
the  muscular  paralysis  develops  within  a  few  weeks  or  many 
months  a  distinction  is  made  between  subacute  and  chronic  polio- 
myelitis. The  character  of  the  paralysis  is  that  already  described 
for  anterior  poliomyelitis  (flaccid  paralysis,  rapid  degenerative 
muscular  atrophy,  degenerative  electric  reaction,  abolished  reflexes, 
preservation  of  cutaneous  sensibility,  retained  functional  activity 
of  the  bladder  and  the  rectum).  AVhen  the  paralysis  has  existed 
for  some  time  muscular  contracture  may  develop.  The  duration 
of  the  disease  may  extend  over  four  years. 

The  anatomic  alterations  consist  in  disappearance  of  the 
large  motor-trophic  ganglion-cells  in  the  anterior  horns.  In  addi- 
tion, changes  in  the  blood-vessels  (thickening  of  the  wall,  nuclear 
nuiltiplication  and  hyperplasia  of  the  neuroglia)  may  occur.  De- 
generation and  atrophy  of  nerve-fibers  also  have  been  found  in 
the  anterior  nerve-roots  and  in  the  peripheral  nerves. 

In  some  cases  areas  of  degeneration  have  been  found  in  some  columns 
of  the  cord  and  disappearance  of  ganglion-cells  in  the  columns  of  Clarke. 

The  diagnosis  is  not  always  easy.  Subacute  and  chronic 
anterior  poliomyelitis  is  distinguished  from  spinal  progressive  mus- 
cular atrophy  hj  the  fact  that  progressive  muscular  atrophy  gener- 
ally begins  in  the  muscles  of  the  hand,  that  atrophy  of  the  muscles 
precedes  paralysis,  and  that  the  atrophy  involves  the  muscles  only 
in  bundles  (fascicular),  and  not  totally  as  in  cases  of  anterior  polio- 
myelitis. Amyotrophic  lateral  sclerosis  is  attended,  in  addition  to 
muscular  wasting  and  contractures,  especially  with  exaggeration 


588  XERVOUS  SYSTEM 

of  the  tendinous  and  periosteal  reflexes.  Finally,  in  the  presence 
of  progressive  polyneuritis  sensory  disturbances  are  generally  pres- 
ent in  addition  to  motor  disorders. 

The  prognosis  and  the  treatment  are  the  same  as  for  acute 
spinal  paralysis  of  childhood. 

SPINAL  PROGRESSIVE  MUSCULAR  ATROPHY. 

Ktiology. — Little  of  a  definite  nature  is  known  with  regard 
to  the  etiology  of  spinal  progressive  muscular  atrophy.  The  dis- 
ease, which  is  uncommon,  occurs  more  frequently  in  men,  and,  as  a 
rule,  develops  only  after  the  thirtieth  year  of  life.  Among  the  causati  ve 
factors  exposure  to  cold,  over-exertion',  traumatism,  and  antecedent 
infectious  disease  have  been  mentioned.  In  exceptional  instances 
spinal  progressive  muscular  atrophy  has  been  observed  in  persons 
that  in  early  life  had  suffered  from  spinal  paralysis  of  chUdhood. 
On  the  other  hand,  heredity,  in  contradistinction  from  the  myo- 
pathic form  of  progressive  muscular  atrophy,  is  not  of  especial 
etiologic  significance. 

Anatomic  Alterations. — There  is  a  great  deficiency  in  good 
and  reliable  anatomic  descriptions.  The  disease  is  characterized 
by  disappearance  of  the  large  motor-tropliic  ganglion-cells  in  the 
anterior  horns  of  the  spinal  cord.  At  the  same  time  the  ganglion- 
cells  frequently  become  filled  with  yellowish  or  yellowish-brown, 
granular  pigment,  undergo  progressive  contraction  to  small  round- 
ish structures  without  processes  (so-called  pigmentary  degenera- 
tion of  the  ganglion-cells),  and  finally  undergo  c(miplete  destruc- 
tion, while  neuroglia  takes  their  place.  The  destruction  of  each 
ganglion-cell  is  necessarily  followed  by  degeneration  of  the  entire 
spinal-peripheral  neuron,  and  accordingly  degeneration  and  atrophy 
of  the  nerve-fibers  can  be  traced  in  the  related  anterior  nei-ve-roots 
of  the  spinal  cord  and  in  the  peripheral  nerves  to  the  muscles. 
The  diseased  muscles  exhibit  marked  atrophy  and  a  light,  usually 
brownish  color.  The  loss  of  individual  muscle-fibers  can  be  seen 
with  especial  distinctness  on  transverse  section,  while  the  inter- 
stitial connective  tissue  is  abnormally  increased  and  generally 
contains  many  nuclei.  In  many  places  muscle-fibers  are  replaced 
by  remains  of  granular,  yellow  or  brownish  pigment.  Here  and 
there  abnormally  dilated  blood-vessels  with  thickened  walls  can 
be  seen.  In  addition  to  atrophic  muscle-fibers  a  greater  or  lesser 
number  of  hypertrophied  muscle-fibers  are  present,  and  which  not 
rarely  exhibit  vacuoles  and  nests  of  nuclei. 

The  disapi^earance  of  the  muscuhir  fibers  occurs  in  various  ways.  Mus- 
cular fibers  can  be  seen  that  are  characterized  by  marked  diminutiveness, 
distinct  transverse  striation,  and  an  abundance  of  sarcolemma-nuclei.  Other 
muscle-fibers,  on  the  other  hand,  exhibit  arranular  turbidity,  fatty  degenera- 
tion, fibrillary  or  discoid  disintegration  or  fibriUation  as  in  the  case  of  vitreous 
muscular  degeneration. 


DISEASE  OF  GAXGLIOX-CELLS  OF  AXTERIOH  HORNS    589 

Symptoms. — Muscular  atrophy  and  the  muscular  weakness 
and  muscular  paralysis  dependent  thereon  generally  appear  first 
in  the  small  muscles  of  the  hand,  in  the  thenar  and  hypothenar 
eminences,  in  the  interosseous  and  the  lumbrical  muscles.  Then 
the  extensors  upon  the  dorsal  aspect  of  the  forearm  are  involved, 
next  the  deltoid  muscle,  and  only  subsequently  the  muscles  of  the 
upper  arm.  The  process  may  gradually  extend  to  the  muscles  of 
the  trunk.  The  muscles  of  the  leg  either  remain  exempt  or  are 
involved  only  late.  Not  rarely  the  disease  extends  from  the 
ganglion-cells  of  the  anterior  horns  of  the  cervical  portion  of  the 
spinal  cord  to  the  ganglion-cells  of  the  nuclei  of  the  cerebral 
nerves  on  the  floor  of  the  fourth  ventricle,  which  have  the  same 
functions  as  the  ganglion-cells  of  the  spinal  cord.  The  nuclei 
of  the  hypoglossal,  vago-accessory,  glossopharyngeal,  and  facial 
nerves  especially  are  involved,  and,  accordingly,  to  the  symptoms 
of  spinal  progressive  muscular  atroj)hy  the  clinical  picture  of 
chronic  progressive  bulbar  paralysis  is  superadded.  JSTaturally, 
the  reverse  may  happen ;  that  is,  progressive  bulbar  paralysis 
develops  first,  the  disease  of  the  ganglion-cells  extending  from 
the  nuclei  of  the  cerebral  nerves  to  the  ganglion-cells  of  the  cer- 
vical cord,  with  the  development  secondarily  of  spinal  progressive 
muscular  atrophy. 

The  muscles  of  the  right  hand  are  involved  somewhat  earlier 
than  those  of  the  left.  Only  in  left-handed  persons  and  in  those 
whose  work  requires  greater  use  of  the  left  hand  does  the  disorder 
begin  in  this  hand.  In  either  event  the  other  hand  also  is  soon 
involved,  and  the  disease  then  exhibits  a  symmetric  distribution. 
The  disorder  usually  sets  in  insidiously.  The  patients  generally 
note  at  first  undue  readiness  of  fatigue  and  awkwardness  in  the 
movements  of  the  fingers,  and  on  more  careful  examination  it  will 
be  found  that  the  thenar  and  hypothenar  eminences  have  lost  their 
fulness  and  are  flattened,  so  that  the  subjacent  metacarpal  bones 
can  be  readily  reached.  The  thumb  is  often  abducted  and  ex- 
tended, so  that  the  so-called  ape's  hand  results,  as  long  as  the 
extensors  of  the  thumb  and  the  long  adductor  upon  the  dorsal 
aspect  of  the  forearm  remain  intact.  Interosseous  spaces  of 
unusual  depth  upon  the  dorsum  of  the  hand  result  from  atrophy 
of  the  interosseous  muscles,  and  disappearance  of  the  lumbrical 
muscles  will  be  disclosed  by  apparent  excavation  of  the  palm  of 
the  hand  and  prominence  of  the  tendons  of  the  flexors  of  the 
fingers  beneath  the  skin  of  the  palm.  Weakness  of  the  interossei 
often  gives  rise  to  the  claw-hand.  The  more  marked  the  muscular 
atrophy  the  greater  is  the  weakness  of  the  wasted  muscles  and 
the  more  pronounced  is  the  functional  disturbance  in  the  fingers. 

Muscular  wasting  in  the  extensors  upon  the  dorsal  aspect  of 
the  forearm  gives  rise  to  an  appearance  of  emaciation  and  flattening. 
The  interosseous  space  between  the  ulna  and  the  radius  often  is 


590 


NERVOUS  SYSTEM 


distinctly  recognizable  as  a  deep  depression,  and  the  borders  of  the 
radius  and  the  ulna  can  be  readily  palpated  (Fig.  81).  The 
supinators  long  remain  intact,  undergoing  atrophy  only  when  the 
biceps  and  the  internal  brachial  in  the  upper  arm  are  involved. 
In  the  presence  of  atrophy  of  the  deltoid  the  region  of  the  shoulder 


Fig.  81. — A  man,  52  years  old,  with  s]iinal  prri-res.-i  ve  muscular  atrophy ;  from  a  photograph 
(persoual  observation.  Zurich  clinic). 

appears  flattened,  and  the  head  and  the  neck  of  the  humerus  are 
readily  accessible  through  the  skin.  At  times  a  depression  between 
the  head  of  the  humerus  and  the  acromion  process  is  appreciable  on 
ocular  inspection.  This  is  indicative  of  a  flail-joint,  which  results 
from  the  fact  that  the  deltoid  is  so  greatly  weakened  in  its  powers 
that  the  forearm  by  reason  of  its  weight  drops  downward  and  its 


DISEASE  OF  GANG  LION-CELLS  OF  ANTERIOR  HORNS    591 

articular  head  is  separated  from  the  glenoid  cavity.  The  weakness 
of  the  deltoid  muscle  is  characterized  particularly  by  an  inability 
to  raise  the  arm  to  the  horizontal  level  at  all  perfectly  or  for  more 
than  a  short  time.  Of  the  muscles  of  the  upper  arm,  the  triceps 
remains  uninvolved  the  longest. 

An  exceedingly  common  symptom  of  spinal  progressive  atrophy 
is  fascicular  (fibrillary)  muscular  contraction.  This  consists  in  sud- 
denly occurring  and  rapidly  disappearing  muscular  twitching,  in- 
volving isolated  muscle-bundles.  At  times  it  is  so  persistent 
and  distributed  among  so  many  muscles  that  these  appear  to  be 
in  a  condition  of  constant  restlessness.  In  other  cases,  however, 
a  long  time  elapses  before  the  muscular  twitching  becomes  visible. 
It  can  often  be  induced  artificially  by  percussion,  by  blowing  upon 
the  skin  or  spraying  it  with  cold  water.  Nothing  of  a  definite 
nature  is  known  with  regard  to  its  development.  It  occurs  tran- 
siently also  in  healthy  persons  under  the  influence  of  cold,  as, 
for  instance,  on  removal  of  the  clothing.  Degenerative  electric 
reaction  is  present  in  the  atrophied  muscles,  although  the  exam- 
ination requires  skill  and  attention,  as  the  atrophy,  and  accord- 
ingly also  the  degenerative  electric  reaction,  are  often  present 
only  in  bundles  of  muscles.  All  reflex  movements  (cutaneous, 
tendinous,  and  periosteal  reflexes)  are  wanting,  or  at  least  are 
enfeebled,  in  the  distribution  of  the  affected  muscles.  Cutaneous 
sensibility  remains  unchanged,  but  not  rarely  the  diseased  nerves 
and  muscles  are  sensitive  to  pressure.  Vasomotor  disturbances 
occur  frequently,  and  give  rise  to  cyanotic  discoloration  and  cold- 
ness of  the  skin,  particularly  in  the  fingers,  hands,  and  forearms. 
At  times  trophic  disturbances  occur,  as,  for  instance,  thickening 
and  brittleness  of  the  skin,  abnormal  growth  of  hair,  pemphigus, 
herpes,  thickening  of  tendons  or  joints.  The  functions  of  the 
bladder  and  the  rectum  remain  undisturbed. 

The  disease  pursues  an  extremely  slow  course  and  sometimes 
extends  over  many  years.  The  greater  the  number  of  arm-muscles 
that  waste  and  become  incapacitated  functionally  the  greater  is 
the  degree  of  helplessness  of  the  patient.  Muscular  contractures 
also  develop  gradually.  If  the  extensors  of  the  back  are  involved 
in  atrophy  and  paralysis,  the  patient  eventually  will  be  unable  to 
assume  the  erect  position  unaided.  If  bulbar  symptoms  are  super- 
added, the  tongue  undergoes  wasting,  becomes  movable  with  diffi- 
culty, and  exhibits  fibrillary  contractions,  and  difficulties  in  speech 
and  in  the  formation  of  a  bolus  develop  as  a  result  of  hypoglossal 
paralysis.  Difficulty  in  swallowing,  paralysis  of  the  laryngeal 
muscles,  and  acceleration  of  the  action  of  the  heart  occur  (paral- 
ysis of  the  glossopharyngeal  and  vago-accessory).  The  muscles 
of  the  face,  and  especially  those  of  the  lips  and  the  cheeks, 
become  thin,  atrophied,  and  stiff",  and  movable  with  difficulty 
(facial  palsy).    The  complication  is  of  serious  significance,  because 


592  NERVOUS  SYSTEM 

death  may  result  rapidly  in  consequence  of  inspiration-pneumonia 
or  paralysis  of  respiration  or  of  cardiac  action. 

Diagnosis. — The  diagnosis  of  spinal  progressive  muscular 
paralysis  can  scarcely  be  considered  difficult.  Confusion  might 
most  likely  occur  with  myopathic  and  neural  progressive  muscular 
atrophy;  that  is,  with  those  varieties  of  progressive  muscular 
wasting  and  paralysis  dependent  upon  disease  of  the  muscular 
structure  itself  or  of  the  peripheral  nerves.  In  the  differential 
diagnosis  it  should  be  borne  in  mind  that  myopathic  and  neural 
progressive  muscular  atrophy  are  frequently  hereditary,  begin  at 
times  in  early  life,  and  frequently  commence  in  the  muscles  of  the 
legs  or  the  facial  muscles,  or  in  the  muscles  of  the  shoulder-girdle. 
The  same  muscular  changes  as  occur  in  spinal  muscular  atrophy  are 
observed  also  in  syringomyelia,  but  the  latter  is  attended  besides 
with  partial  anesthesia  and  trophic  disorders.  Spinal  progressive 
muscular  atrophy  is  distinguished  from  subacute  and  chronic  ante- 
rior poliomyelitis  by  the  fact  that  in  the  former  muscular  atrophy 
appears  first,  and  then  weakness  and  paralysis  of  the  atrophic  mus- 
cles while  in  poliomyelitis  paralysis  appears  first,  and  then  atrophy 
of  the  paralyzed  muscles  occurs.  Chronic  polyneuritis  does  not 
pursue  the  typical  course  of  spinal  progressive  muscular  atrophy, 
and  it  is  generally  attended  also  with  sensory  disturbances.  Occa- 
sionally muscular  atrophy  complicates  antecedent  arthritis.  Under 
such  circumstances  only  a  few  muscles  in  the  vicinity  of  the  in- 
flamed joint  are  involved. 

Prognosis. — Spinal  progressive  muscular  atrophy  is  an  in- 
curable disease  of  progressive  course  and  distribution.  The  prog- 
nosis is  therefore  unfavorable.  Life  naturally  may  be  preserved 
for  many  years,  particularly  if  bulbar  symptoms  do  not  occur. 

Treatment. — Internal  remedies  are  without  effect.  In  the 
first  place,  massage  of  the  affected  muscles  may  be  recommended. 
At  least,  no  more  can  be  accomplished  by  electric  treatment  of  the 
muscles.  Baths  (indifferent,  saline,  sulphurous)  have  also  been 
employed. 

COMBINED   SYSTEM-DISEASES  OF  THE  SPINAL 

CORD. 

HEREDITARY  ATAXIA. 

Ktiology. — Hereditary  ataxia  is  an  uncommon  disease,  first 
carefully  studied  by  Friedreich,  and  therefore  known  also  as 
Friedreich^ s  ataxia.  The  disorder  is  generally  an  hereditary  or 
familial  one,  and  boys  are  more  commonly  attacked  than  girls. 
Mental  disease  and  alcoholism  in  the  parents,  as  well  as  antecedent 
infectious  disease,  have  been  named  as  causative  factors. 

Symptoms  and  Diagnosis. — The  disease  generally  begins 


AMYOTROPHIC  LATERAL  SCLEROSIS  593 

ill  chilclhoocl  (between  the  third  and  the  seventh  year)  or  at  the 
period  of  puberty.  The  most  conspicuous  symptom  is  the  mark- 
edly ataxic  gait,  whicli  is  suggestive  of  the  staggering  of  an  intoxi- 
cated person.  Marked  swaying  of  the  body  is  noticeable  particu- 
larly on  standing — static  ataxia.  The  ataxia  soon  extends  from 
the  legs  to  the  arms.  In  walking  the  head  is  involved  in  active 
oscillation.  The  muscles  of  articulation  and  the  ocular  muscles 
also  are  involved  in  the  ataxia,  with  the  development  of  ataxic 
anarthria  and  ataxic  nystagmus.  Swaying  of  the  body  when  the 
eyes  are  closed  is  frequently,  though  not  invariably,  present.  The 
knee-jerk  is  almost  always  absent.  The  foot  often  exhibits  deform- 
ities, and  the  great  toe  is  generally  in  a  position  of  dorsal  flexion. 
Spinal  curvature  also  is  frequent.  In  contradistinction  from  ordi- 
nary tabes  dorsalis  sensory  disturbance,  visceral  crises,  paralysis  of 
the  bladder  and  the  rectum,  trophic  changes,  reflex  immobility  of 
the  pupils,  paralysis  of  ocular  muscles,  and  optic  atrophy  are 
almost  always  wanting.  The  disease  pursues  a  chronic  course,  and 
at  times  may  extend  over  more  than  thirty  years.  Death  usually 
results  from  some  accidentally  intercurrent  disease. 

Anatomic  Alterations. — Disappearance  of  nerve-fibers  and 
proliferation  of  neuroglia  are  found  in  the  spinal  cord  in  the  poste- 
rior columns,  in  the  lateral  pyramidal  tracts,  in  the  lateral  cerebellar 
tracts,  and  in  the  tracts  of  Gowers  (Fig.  82).  Disappearance  of 
ganglion-cells  and  of  nerve-fibers  has  been  observed  also  in  the 
columns  of  Clarke.  The  posterior  spinal  nerve-roots  are  often 
thin,  atrophic,  and  gray.  Nerve-degeneration  has  been  observed 
also  in  peripheral  nerves.  Recently  attention  has  been  called 
by  several  observers  to  atrophy  of  the  cerebelliun,  and  there  is  a 
tendency  to  ascribe  the  staggering  gait  to  this  condition  (cerebellar 
ataxia).  There  is  much  in  favor  of  the  view  that  the  anatomic 
alterations  result  from  defective  development  of  individual  por- 
tions of  the  spinal  cord  and  the  cerebellum. 

Prognosis  and  Treatment.— There  can  be  no  hope  of 
therapeutic  success,  and  the  prognosis  is  therefore  unfavorable 
with  regard  to  recovery. 

AMYOTROPHIC  LATERAL  SCLEROSIS. 

Ktiologfy. — Amyotrophic  lateral  sclerosis  is  a  rare  disease, 
which  is  observed  more  comraonly  in  women  than  in  men,  and 
generally  appears  between  the  thirti/-fifth  and  the  fiftieth  year  of  life. 
Exposure  to  cold,  traumatism,  and  emotional  disturbances  have  been 
mentioned  as  causative  factors.  Lead-poisoning  also  is  thought 
to  be  responsible  for  the  disease.  Isolated  observations  have  been 
made  pointing  to  the  hereditary  and  familial  occurrence  of  the 
disorder. 

Anatomic  Alterations. — The  affection  represents  a  disease 

38 


594  NERVOUS  SYSTEM 

of  the  motor-lateral  pjrramidal  tracts  and  the  motor-trophic  ganglion- 
cells  in  the  anterior  horns  of  the  spinal  cord,  and  accordino;ly  con- 
sists in  a  combination  of"  the  symptoms  of  lateral  sclerosis  and 
those  of  chronic  anterior  poliomyelitis.  The  disease  of  the  lateral 
pyramidal  tracts,  which  consists  in  loss  of  nerve-fibers  and  in- 
crease of  neuroglia,  occurs  first,  and  may  at  times  be  followed 
toward  the  brain  throughout  the  entire  motor  or  corticomuscular 
path  to  the  motor  ganglion-cells  of  the  cerebral  cortex.  Likewise 
the  disease  of  the  ganglion-cells  of  the  anterior  horns  (atrophy, 
disappearance  of  ganglion-cells,  and  proliferation  of  neuroglia) 
causes  degeneration  and  atrophy  of  nerve-fibers  in  the  anterior 
spinal  nerve-roots,  and  in  the  peripheral  nerves  to  the  muscles. 
The  muscles  themselves  also  may  exhibit  degenerative  atrophy. 
The  entire  motor  path  from  the  cerebral  cortex  to  the  peripheral 
muscle-termination  is  thus  involved  in  cases  of  amyotrophic  lat- 
eral sclerosis,  and  the  alterations  consist  in  degenerative  atrophy 
of  the  cerebrospinal  and  spinal-peripheral  motor  neuron.  In  iso- 
lated cases  the  anterior  (direct)  pyramidal  tracts,  and  even  the 
columns  of  Goll,  also  have  been  found  degenerated.  Disappear- 
ance of  ganglion-cells  of  the  posterior  horns  of  the  spinal  cord  has 
likewise  been  observed. 

Symptoms  and  Prognosis. — In  accordance  w-ith  the  motor 
alterations,  the  clinical  manifestations  consist  of  a  combination  of 
the  symptoms  of  spastic  spinal  paralysis  (paralysis,  contracture, 
exaggeration  of  the  tendinous,  periosteal,  and  cutaneous  reflexes) 
and  those  of  chronic  anterior  poliomyelitis  (muscular  atrophy, 
degenerative  electric  reaction  in  the  atrophied  muscles).  The 
disease  begins  in  the  arms,  and  extends  tiience  to  the  muscles  of 
the  trunk  and  the  lower  extremities.  In  the  latter  only  spastic- 
paretic,  and  not  atrophic,  alterations  become  apparent.  It  is 
noteworthy  that  the  atrophy  of  the  ganglion-cells  of  the  anterior 
horns  may  extend  to  the  nuclei  of  the  hypoglossal,  vagus-acces- 
sory, glossopharyngeal,  and  facial  nerves,  and  less  commonly  also 
to  those  of  the  trigeminus  and  the  abducens,  so  that  symptoms  of 
progressive  bulbar  paralysis  develop. 

The  disease  often  begins  with  paresthesise  in  the  arms,  partic- 
ularly with  pain,  formication,  burning,  and  a  sense  of  coldness. 
To  these  weakness  and  even  paralysis  of  the  muscles  of  the  arms 
become  superadded.  At  the  same  time  muscular  contractures  also 
develop.  The  arms  become  adducted  to  the  thorax,  the  forearms 
are  flexed  at  the  elbow-joint,  and,  particularly,  marked  flexor- 
contracture  develops,  with  associated  pronation  in  the  joints  of 
the  hand  and  flexor-contracture  of  the  fingers.  Tlie  tendinous 
and  periosteal  reflexes  are  abnormally  increased.  To  the  symp- 
toms described,  muscular  atrophy  is  su])eradded.  This  frequently 
begins  in  the  small  muscles  of  the  fingers  and  the  hand,  then 
extends  to  the  extensor  muscles  upon  the  dorsal  aspect  of  the 


AMYOTROPHIC  LATERAL  SCLEROSIS 


595 


Cervical  portion 


Dorsal  portion — 


forearm,  invades  the  deltoid  and  other  muscles  of  the  upper  arm, 
and  latest,  if  at  all,  involves  the  flexor-muscles  of  the  forearm. 
It  is  noteworthy  that  the  muscles  do  not  undergo  fascicular  atro- 
phy or  wasting  in  bundles,  but  throughout  their  entire  extent. 
The  atrophic  muscles  exhibit  fas- 
cicular (fibrillary)  contractions  and 
degenerative  electric  reaction. 

Should  the  changes  in  the  spinal 
cord  extend  downward  from  the  cer- 
vical portion,  the  patients  complain 
of  stiffness  in  the  back  if  the  mus- 
cles in  this  situation  become  in- 
volved. Involvement  of  the  mus- 
cles of  the  lower  extremity  will  be 
indicated  by  weakness  and  a  spas- 
tic-paretic  gait.  The  patients  make 
short,  stumbling  steps,  scrape  the 
feet  upon  the  ground  in  walking, 
move  the  legs  rigidly  like  stilts, 
and  in  consequence  of  contracture 
of  the  abductors  push  one  thigh 
before  the  other  with  difficulty. 
At  the  same  time  the  knee-jerk 
and  ankle-clonus  are  greatly  in- 
creased. Cutaneous  sensibility  and 
the  functions  of  the  bladder  and 
the  rectum  exhibit  no  alteration. 
Should  bulbar  symptoms  appear, 
the  tongue  undergoes  atrophy, 
with  the  development  of  disturb- 
ances in  the  formation  of  the 
bolus  and  in  articulation  (hypo- 
glossal paralysis).  The  muscles 
of  the  chin  and  the  cheek  undergo 
wasting  and  become  rigid.  The 
masseteric  reflex  is  exaggerated. 
In  consequence  of  vago-accessory 
and  glossopharyngeal  paralysis  dif- 
ficulty in  swallowing,  paralvsis  of 
the  laryngeal  muscles,  and  tacliy- 
cardia  occur.  Inspiration-pneumonia  and  paralysis  of  respiration 
or  of  the  heart  are,  therefore,  frequent  causes  of  death.  The  dis- 
order generally  terminates  fatally  in  from  one  to  three  years. 
Recovery  has  been  observed  but  rarely. 

The  progfnosis  is  grave. 

Diagnosis. — In  the  diagnosis  care  should,  in  the  first  place, 
be  observed  to  avoid  confusion   with   spinal  progressive   muscular 


Lumbar  portion 
of  the  spinal 
cord 


Fig.  82.— Anatomic  alterations  in  the 
spinal  cord  from  a  case  of  hereditary 
ataxia ;  the  diseased  areas  are  shaded 
(after  Friedreich  and  Schultze). 


596  NERVOUS  SYSTEM 

atrophy,  although  in  cases  of  tlie  latter,  conversely  from  amyo- 
trophic lateral  sclerosis,  the  atrophy  precedes  the  muscuhir  paral- 
ysis, and  the  reflex  movements  are  diminished  or  even  al)olished. 
Amyotrophic  lateral  sclerosis  is  generally  distinguishaljle  from 
syringomyelia  from  the  presence  of  partial  sensory  loss  and  trophic 
disturbances  in  the  latter.  In  the  presence  of  hypertrophic  cervical 
pachymeningitis  irritative  symptoms  (pain)  preponderate,  and,  in 
addition,  other  sensory  disturbances  occur  and  bulbar  symptoms 
are  wanting. 

Treatment. — Good  results  are  reported  from  the  administra- 
tion of  potassium  iodid  (5.0  :  200 — 75  grains  :  Q\  fluidounces  ;  15 
c.c. — 1  tablespoonful  thrice  daily)  and  sulphurous  baths  (potassium 
sulphid,  150 — 5  ounces — to  a  full  bath  at  a  temperature  of  28°  E,. 
_35o  c.— 95°  F.). 

Secondary  Degeneration  of  Individual  Columns  of  the  Cord. — 
Secondary  degeneration  of  the  spinal  cord  is  rather  of  anatomic 
than  of  clinical  interest,  so  that  a  brief  reference  to  the  subject 
must  suffice.  The  reason  for  its  occurrence  is  found  in  the  cir- 
cumstance that,  in  accordance  with  the  so-called  law  of  Waller, 
the  peripheral  portions  of  nerve-fibers  that  are  separated  from 
their  trophic  centers  undergo  degeneration  and  atrophy.  Three 
varieties  of  secondary  degeneration  of  the  spinal  cord  may  be 
distinguished,  namely,  an  ascending,  a  descending,  and  a  mixed 
form. 

Descending  secondary  degeneration  of  the  spinal  cord  always  de- 
velops when  the  corticomuscular  or  motor  pyramidal  tract  is  inter- 
rupted at  any  point  in  its  course,  so  that  the  motor  paths  toward 
the  peripheral  side  of  the  focus  of  disease  are  cut  oif  from  their 
trophic  center,  the  motor  pyramidal  cells  in  the  motor  cortical 
center  in  the  anterior  and  posterior  central  convolutions  of  the 
cerebrum.  This  condition  occurs  most  commonly  as  the  result  of 
cerebral  hemorrhage,  which  generally  takes  place  into  the  internal 
capsule.  The  degenerated  pyramidal  tract  may  be  visible  in  ad- 
vanced cases  to  the  naked  eye  in  the  middle  portion  of  the  foot  of 
the  related  cerebral  peduncle  and  in  the  pons.  Within  the  pyram- 
idal decussation  of  the  medulla  oblongata  the  greater  portion  of 
the  degenerated  nerve-fibers  cross  over  into  the  lateral  (crossed) 
pyramidal  tract  of  the  opposite  half  of  the  spinal  cord,  and  only 
a  small  portion  remain  upon  the  same  side  and  continue  their 
course  in  the  anterior  (direct)  pyramidal  tract  (p.  597,  Fig.  83). 
In  the  cervical  and  dorsal  portions  of  the  spinal  cord  the  lateral 
pyramidal  tracts  are  se})arated  further  from  the  periphery  of  the 
cord  by  the  lateral  cerebellar  tracts.  In  the  lumbar  region,  how- 
ever, the  lateral  pyramidal  tracts  reach  the  periphery  of  the  cord 
and  terminate  at  about  the  level  of  the  third  or  fourth  sacral  nerve. 
In  some  cases  the  direct  pyramidal  tract  is  wholly  wanting,  as,  for 


AMYOTROPHIC  LATERAL  SCLEROSIS 


597 


instance,  in  the  accompanying  illustration,  while  in  other  cases, 
on  the  contrary,  it  may  be  larger  than    the  crossed  pyramidal 


Cerebral  peduncle 


Pons 


Middle  of  the  olive 


Pyramidal  decussation 

Middle  of  the  cervical 
enlargement 

Middle    of  the   dorsal 
segment 

Middle  of  the  lumbar 
enlargement 

Conus  medullaris 


Fig.  83.— Descending:  secondary  degeneration  of  the  right  lateral  pyramidal  tract  in 
conseqnence  of  hemorrhagic  encephalbmalacia  of  the  left  internal  capsule;  hardened  in 
Miiller's  fluid  ;  natural  size  (personal  observation,  Zurich  clinic). 


tract.  Anatomically,  there  results  degenerative  atrophy  of  nerve- 
fibers,  to  which  proliferation  of  the  neuroglia  becomes  superadded. 
Further,  even  marked  degeneration  is  frequently  not  distinguish- 


598 


NER  VO  US  SYSTEM 


Middle  of  the  olivary  body ' 


Middle  of   the    pyramidal 
decussation 


Uppermost  portion  of  the  ___ 
cervical  cord 

Middle  of  the  cervical  en- 
largement 

Lower  portion  of  the  cervi- 

cal  cord 

1  cm.  above  the  point  of 

compression  ^i^JI 

Point  of    compression 
(fourth  dorsal  vertebra^ 

1.5  cm.  below  the  point  of 
compression 


Middle  of  the  dorsal  cord 


Lower  portion  of  the  dorsal  _ 

cord 

Middle  of  the  lumbar  en- 

largement 

Con  us  medullaris 

Fig.  84.— Compression-myelitis  in  a  man,  62  years 
old,' resulting  from  tuberculosis  of  the  fourth  dorsal 
vertebra:  natural  size;  hardened  in  Miiller's  fluid 
(personal  observation,  Zurich  clinic). 


able  in  the  fresh  cord, 
although  it  at  once 
becomes  most  distinct 
after  hardening  in  Miil- 
ler's fluid.  Descending 
secondary  degeneration 
of  the  spinal  cord  is  be- 
yond the  possibility  of 
diagnosis.  In  patients 
with  this  lesion  muscu- 
lar contractures  and  ex- 
aggeration  of  the  reflexes 
are  often  present ;  but 
it  has  not  been  demon- 
strated that  these  phe- 
nomena are  dependent 
upon  the  secondary  de- 
generation in  the  cord. 
Both  manifestations 
might  be  the  result  of 
long-continued  paralysis, 
without  etiologic  relation 
to  each  other. 

Ascending  secondary- 
degeneration  of  the  spi- 
nal cord  is  in  its  pure 
form  a  rare  disorder. 
It  has  been  observed  in 
isolated  cases  in  associa- 
tion with  neoplasms  com- 
pressing the  roots  of  the 
Cauda  equina.  It  has  also 
been  developed  experi- 
mentally in  animals  by 
division  of  the  posterior 
nerve-roots  of  the  spinal 
cord.  In  the  immediate 
neighborhood  of  the  site 
of  injury  degeneration 
was  found  in  the  postero- 
external or  columns  of 
Burdach,  but  the  degen- 
eration extended  upward 
into  the  postero-internal 
or  columns  of  Goll,  and 
it  was  observed  that  the 
degenerated  nerve-fibers 


ACUTE  ASCENDING  SPINAL  PARALYSIS  599 

at  progressively  higher  levels  more  closely  approached  the  pos- 
terior median  fissure  and  advanced  forward. 

Mixed  secondary  degeneration  of  the  spinal  cord  develops  after 
transverse  lesions  of  the  cord.  Below  the  seat  of  disease  the 
lateral  and  the  anterior  pyramidal  tracts  upon  either  side  undergo 
degeneration.  Above  the  transverse  lesion,  however,  ascending 
degeneration  takes  place  in  the  columns  of  Goll,  in  the  lateral 
cerebellar  tracts,  and  in  the  bundles  of  Gowers  in  front  of  the 
latter  (p.  598,  Fig.  84).  As  is  well  known,  the  intervertebral  gan- 
glia represent  the  trophic  centers  for  the  columns  of  Goll,  and  the 
columns  of  Clarke  those  for  the  lateral  cerebellar  tracts.  As  the 
columns  of  Clarke  extend  only  down  to  the  lower  part  of  the 
dorsal  cord,  transverse  lesions  in  the  lumbar  cord  will  not  be  fol- 
lowed by  secondary  degeneration  of  the  lateral  cerebellar  tracts. 
Further,  diffuse  (traumatic)  degeneration  of  the  spinal  cord  will 
occur  in  the  immediate  neighborhood  of  the  seat  of  disease,  and 
the  columnar  degeneration  will  begin  a  slight  distance  beyond. 

FUNCTIONAL  DISOKDEKS  OF  THE  SPINAL 

CORD  OR  NEUROSES  OF  THE  SPINAL 

CORD. 

ACUTE  ASCENDING   SPINAL  PARALYSIS* 

Symptoms,  Prognosis,  and  Anatomic  Alterations. — 

Acute  ascending  spinal  paralysis,  also  known  as  Landry's  paral- 
ysis, either  sets  in  suddenly  or  is  preceded  by  slight  chill,  febrile 
movement,  pain  in  the  back  and  in  the  extremities,  and  paresthe- 
sise  as  prodromes.  The  patient  is  conscious  of  weakness  in  one 
lower  extremity  or  perhaps  simultaneously  in  both,  and  the  weak- 
ness soon  gives  place  to  marked  flaccid  paralysis.  While  at  first 
only  the  muscles  of  the  foot  are  involved,  soon  those  of  the  leg 
and  then  those  of  the  thigh  become  paralyzed,  and  then  the  paral- 
ysis extends  to  the  abdominal,  dorsal,  and  thoracic  muscles,  to  the 
arms,  and  finally  also  to  the  tongue,  the  pharyngeal  muscles,  and 
the  vago-accessory  nerve,  with  the  development  of  difficulty  in 
breathing  and  accelerated  heart-action.  Other  cerebral  nerves 
(facial,  abducens)  are  rarely  involved  in  the  paralysis.  Occasionally 
death  takes  place  within  a  few  days  as  the  result  of  inspiration- 
pneumonia  or  respiratory  or  cardiac  paralysis,  while  in  other 
instances  it  is  deferred  for  several  weeks. 

The  paralyzed  muscles  exhibit  unchanged  electric  irritability, 
and  waste,  if  at  all,  only  after  the  paralysis  has  existed  for  some 
time  (atrophy  from  disuse).  The  bladder  and  the  rectum  are  not 
involved  in  the  paralysis.  Sensory  disturbances  are  wanting  or  are 
present  only  in  insignificant  degree.     The  cutaneous  and  tendinous 


600  NERVOUS  SYSTEM 

reflexes  remain  unaltered,  or  become  gradually  enfeebled  after  the 
disease  has  existed  for  some  time.  Trophic  alterations  are  Mant- 
ing,  while  vasomotor  disturbances  (discoloration  of  the  skin,  sweats) 
occur  at  times.  Fever  is  not  present,  as  a  rule.  Consciousness  is 
preserved  until  death  occurs.  In  numerous  instances  enlargement 
of  the  spleen  and  albuminuria  were  present,  so  that  the  appearance 
of  an  infectious  disease  was  created.  Unfortunately,  the  disease 
terminates  fatally  in  the  majority  of  cases.  Improvement  and 
recovery  take  place  l)ut  seldom.  It  is  distinctive  of  the  disease 
that  alterations  in  the  nervous  system  capable  of  explaining  the 
occurrence  of  the  paralysis  cannot  be  found. 

Diagnosis. — The  recognition  of  acute  ascending  spinal  paral- 
ysis is  not  ditiicult  if  the  typical  symptoms  are  borne  in  mind. 
At  times  acute  ascending  myelitis  simulates  the  disorder,  but  the 
former  is  generally  attended  with  sensory  disturbances,  paralysis 
of  the  bladder  and  the  rectum,  and  changes  in  the  tendon-reflexes. 
Acute  ascending  polyneuritis  also  may  give  rise  to  confusion.  It 
should  be  noted  that  in  the  presence  of  the  latter  disease  degener- 
ative electric  reaction  appears  early  in  the  paralyzed  nerves  and 
muscles,  that  the  tendon-reflexes  disappear,  and  that  the  muscles 
imdergo  degenerative  atrophy  within  a  short  time. 

Ktiology. — Exposure  to  cold  and  emotional  disturbances,  but 
with  greater  propriety  antecedent  infectious  disease,  are  named  as 
causes  of  acute  ascending  spinal  paralysis.  The  disorder  is  most 
common  between  the  twentieth  and  the  fortieth  year  of  life,  and 
in  men. 

Treatmetlt. — Inunctions  of  mercurial  ointment  (5.0 — 75  grains 
— daily)  have  been  made,  particularly  if  syphilis  had  previously 
been  present.  No  good  is  to  be  expected  from  nervines.  The 
galvanic  current  also,  applied  to  the  vertebral  column,  would 
scarcely  be  capable  of  controlling  the  disease.  Should  paralysis 
of  deglutition  develop,  it  will  be  necessary  to  nourish  the  patient 
by  means  of  the  stomach-tube. 

REFLEX  PARALYSIS. 

Reflex  paralysis  Avas  looked  upon  until  within  recent  years  as  a 
by  no  means  rare  occurrence,  and  it  was  observed  particularly  in 
the  sequence  of  diseases  of  the  female  generative  apparatus,  the 
kidneys,  and  the  bladder  (urinary  paraplegia),  and  the  intestines 
(dysentery,  intestinal  worms).  Its  occurrence  was  attributed  to 
paralysis  of  the  functions  of  the  spinal  cord,  in  consequence  of 
irritative  conditions  in  various  organs.  It  has,  however,  been 
shown  recently  that  most  cases  of  reflex  paralysis  are  due  to  neu- 
ritis and  myelitis  that  have  developed  by  extension  from  the  dis- 
eased organs.  Nevertheless,  reflex  paralysis  does  appear  to  occur, 
and  in  support  of  this  view  it  may  be  pointed  out  that  some  forms 


INFLAMMATION  OF  THE  SPINAL  DURA   MATER        601 

of  paralysis  disappear  with  surprising  rapidity  after  removal  of 
the  fundamental  disorder. 


PSYCHIC  PARALYSIS. 

Psychic  paralysis  results  from  the  influence  of  profound  emo- 
tional disturbances,  particularly  fright,  whence  also  the  name  of 
Jright-paralysis.  Paraplegia  has  been  observed  also  as  a  result 
of  imagination.  Further,  myelitic  alterations  may  take  place  as 
a  result  of  fright. 

The  treatment  consists  in  encouraging  suggestion  and  in 
making  a  mental  impression  on  the  patient. 

DISEASES  OF  THE  SPINAL  MENINGES. 

INFLAMMATION  OF  THE  SPINAL  DURA  MATER 
(SPINAL  PACHYMENINGITIS). 

Inflammation  of  the  spinal  dura  mater  may  involve  either  the 
outer  or  the  inner  aspect  of  this  membrane,  and  accordingly  a  dis- 
tinction is  made  between  external  and  internal  spinal  pachymenin- 
gitis. Naturally,  it  may  happen  that  an  external  pachymeningitis 
in  particular  may  extend  to  the  inner  aspect  of  the  dura,  and  thus 
give  rise  to  internal  pachymeningitis. 

EXTERNAL  SPINAL  PACHYMENINGITIS. 

!^tiolog"y. — External  spinal  pachymeningitis  occurs  most  com- 
monly as  the  result  of  vertebral  disease  (tuberculosis,  carcinoma). 
At  times  inflammatory  processes  have  invaded  the  vertebral  canal 
through  the  intervertebral  foramina  or,  after  destruction  of  the 
vertebrae,  through  abnormal  o])enings,  and  such  a  condition  has 
been  observed  in  connection  with  cheesy-tuberculous  pleurisy,  car- 
cinoma of  the  esophagus,  syphilitic  ulceration  of  the  pharynx,  and 
deep  bed-sores.  It  is  doubtful  if  the  disease  may  result  from 
exposure  to  cold. 

Anatomic  Alterations. — The  anatomic  alterations  vary 
with  the  causative  factors.  In  some  cases  purulent,  at  times  (in 
the  presence  of  bed-sores)  smeary  and  putrid,  deposits  are  found 
upon  the  outer  aspect  of  the  spinal  dura,  beneath  which  the  tissue 
of  the  dura  is  vividly  reddened  and  swollen.  At  the  same  time 
accumulations  of  pus  may  have  formed  in  the  loose  fatty  connective 
tissue  between  the  dura  and  the  vertebral  column  (spinal  peri- 
pachymeningitis). When  the  meningitis  is  tuberculous,  cheesy 
deposits  are  not  rarely  found  upon  the  spinal  dura,  and  which  may 
be  several  centimeters  thick,  and  may  exert  considerable  pressure 
upon  the  spinal  cord  and  its  roots.     In  cases  pursuing  a  chronic 


602  NERVOUS  SYSTEM 

course  dense,  cicatrix-like  thickening  occurs  upon  the  outer  aspect 
of  the  dura  mater,  and  often  also  connective-tissue  adhesions  to 
surrounding  structures. 

Symptoms,  Diagnosis,  and  Prognosis. — The  disease  is 
attended  with  stiffness  and  pain  in  the  vertebral  column.  Pressure, 
percussion  of  the  vertebral  column,  the  passage  of  a  sponge  dipped 
in  hot  water,  induce  pain  at  the  site  of  the  inflammation.  Xot 
rarely  complaint  is  made  of  girdle-sense  in  consequence  of  irrita- 
tion of  posterior  nerve-roots.  If  spinal  nerve-roots  are  compressed 
by  inflammatory  products  to  such  a  degree  as  to  suffer  loss  of  func- 
tion, paralysis  and  anesthesia  result.  Often  the  clinical  picture  of 
spinal  pressure-paralysis  is  developed. 

In  diagnosis  the  demonstration  of  spinal  deformity  is  im- 
portant, as  this  often  indicates  involvement  of  the  dura.  Never- 
theless, the  diagnosis  is  rather  a  matter  of  probability. 

The  prognosis  varies  with  the  nature  of  the  primary  disorder. 
Recovery  is  possible. 

Treatment. — In  the  treatment  rest,  application  of  ice,  and 
administration  of  potassium  iodid  are  particularly  deserving  of 
consideration.  Recently,  surgical  treatment  has  also  been  attempted 
(opening  of  the  vertebral  column  and  removal  of  cheesy  masses). 

INTERNAL  SPINAL  PACHYMENINGITIS. 

Internal  spinal  pachymeningitis  may  appear  in  one  of  two 
forms  :  either  as  hypertrophic  internal  spinal  pachymengitis  or  as 
hemorrhagic  internal  spinal  pachymeningitis. 

Hypertrophic  internal  spinal  pachymeningitis  is  a  rare  disease, 
which  has  been  attributed  to  exposure  to  cold,  syphilis,  and  alcoholic 
excess.  It  is  characterized  by  connective-tissue  thickening  of  the 
dura,  and  not  rarely  also  of  the  arachnoid  and  the  pia,  so  that  the 
spinal  cord  becomes  surrounded  by  a  thick  band  of  connective  tissue. 
The  process  is  generally  circumscribed,  and  is  situated  in  the 
cervical  portion  of  the  cord  ^vith  relative  frequency,  so  that  the 
condition  has  been  designated  cervical  hypertrophic  pachymenin- 
gitis. The  dangers  consist,  in  the  first  place,  in  irritation  of  the 
nerve-roots  passing  through  the  diseased  tissue,  and  subsequently 
in  paralysis.  Besides,  the  clinical  picture  of  spinal  pressure- 
paralysis  may  be  superadded  in  the  presence  of  excessive  com- 
pression of  the  spinal  cord. 

The  patient  complains  principally  of  sdjfness  and  pain  in  the 
vei'tebr-al  column,  and  often  also  of  a  constricting,  girdle-like  feeling 
in  the  upper  portion  of  the  chest.  In  addition,  there  appear 
neuralgia  in  the  arms  and  various  forms  of  2)<'i''<'sfhesia'  (formica- 
tion, burning).  Also,  muscular  twitching  is  not  rarely  observed  in 
the  arms.  At  times  trophic  disturbances  occur  (thickening  of  the 
epidermis,  formation  of  vesicles).  All  of  these  manifestations 
result  from  irritation  of  the  nerve-roots.     Paralysis  of  the  spinal 


INFLAMMATION  OF  SOFT  MEMBRANES  OF  SPINAL  CORD  G03 

nerve-roots  is  attended  with  cutaneous  anesthesia  and  loss  of  tlie 
reflexes,  and  generally  gives  rise  first  to  paralysis  of  the  muscles 
supplied  by  the  median  and  ulnar  nerves.  The  action  of  the 
extensors  of  the  hand  and  the  fingers  therefore  becomes  predomi- 
nant, and  gives  rise  to  contracture  and  fixation  of  the  hand  in 
dorsal  flexion  and  to  claw-fingers.  The  paralyzed  muscles  rapidly 
undergo  atrophy  and  exhibit  degenerative  electric  reaction.  Finally, 
the  clinical  picture  of  sjjinal  2:)ressure-paralysis  may  be  superadded. 
Paraplegia  develops  in  the  lower  extremities,  the  tendon-reflexes 
become  exaggerated,  and  paralysis  of  the  bladder  and  the  rectum 
occurs. 

The  disease  often  extends  over  years,  and  is  at  times  susceptible 
of  recovery.  It  is  distinguished  from  spinal  progressive  muscular 
atrophy  by  the  predominance  of  the  sensory  disturbances  at  the 
beginning  of  the  disorder,  a  circumstance  that  is  of  importance 
also  in  the  differentiation  from  amyotrophic  lateral  sclerosis,  in 
which  disease,  besides,  the  reflexes  are  exaggerated.  Therapeu- 
tically, employment  may  be  made  especially  of  potassium  iodid 
internally  and  local  applications  of  iodin  and  the  ice-bag. 

Hemorrhagic  internal  spinal  pachymeningitis  may  occur,  together 
with  a  similar  process  of  the  cerebral  dura,  particularly  in  the 
insane  and  in  alcoholics,  and  is  attended  either  with  thin,  vascular 
membranes  that  can  be  scraped  ofl"  with  a  knife,  or  with  blood-sacs 
of  considerable  size  (hematomata),  which  upon  section  are  found 
to  consist  of  discrete  collections  of  blood  of  varying  age,  separated 
from  one  another  by  membranes.  Only  hematomata  at  times  give 
rise  to  symptoms  by  exerting  pressure  upon  the  spinal  cord  and 
the  nerve-roots.  Also,  blood-vessels  at  times  rupture  suddenly  in 
individual  membranes,  with  profuse  hemorrhage,  which  may  com- 
press and  paralyze  the  spinal  cord.  The  diagnosis  cannot  be  made 
with  certainty. 

INFLAMMATION  OF  THE  SOFT  MEMBRANES  OF  THE 
SPINAL  CORD  (SPINAL  MENINGITIS). 

Inflammation  of  the  soft  membranes  of  the  spinal  cord  involves 
the  arachnoid,  but  especially  the  pia.  Arachnitis  and  piitis  are 
grouped  together  under  the  designation  meningitis  (leptomenin- 
gitis), and  a  distinction  is  made  between  acute  and  chronic  spinal 
meningitis. 

ACUTE  INFLAMMATION  OF  THE  SOFT  MEMBRANES  OF  THE 
SPINAL  CORD   (ACUTE  SPINAL  MENINGITIS). 

Anatomic  Alterations. — Acute  spinal  meningitis  is  almost 
always  'purulent  in  character.  The  pia  especially  is  infiltrated  and 
covered  with  yellowish-green  masses  of  pus,  which  are  particularly 
abundant  upon  the  posterior  aspect  of  the  spinal  cord,  because  the 


604  NERVOUS  SYSTEM 

patients  generally  occupy  the  dorsal  decubitus.  In  this  situation 
at  times  the  pus  envelops  the  entire  spinal  cord  in  a  coherent 
membrane,  while  upon  the  anterior  surface  it  is  present  in  insular 
and  disseminated  areas.  The  pia  and  the  arachnoid  exhibit, 
besides,  vascular  hyperemia.  The  veins  are  greatly  distended  Avitli 
blood,  dilated,  and  markedly  tortuous.  Here  and  there  vessels 
have  ruptured,  and  generally  small  extravasations  of  blood  have 
taken  place.  The  cerebrospinal  fluid  is  generally  increased,  and, 
besides,  it  is  usually  flocculeut  and  turbid  and  slightly  purulent. 
The  spinal  cord  is  in  many  cases  unaltered  ;  in  others  it  appears 
hvperemic  and  soft,  and  at  times  it  may  even  contain  small 
abscesses.  Purulent  inflammation  of  the  pia  often  extends  to  the 
spinal  nerve-roots. 

On  microscopic  examination  the  tissue  of  the  pia  and  the  arachnoid  is 
found  swollen  aud  thickened,  and  containing  innumerable  round  cells.  The 
blood-vessels  are  greatly  dilated  and  filled  with  red  blood-corpuscles.  Their 
walls  are  thickened  and  infiltrated  with  round  cells.  In  preparations  stained 
with  aniline  dyes  bacteria  can  be  discovered  in  places  in  recent  cases.  The 
cerebrospinal  fiaid  contains  large  numbers  of  pus-corpuscles.  These  fre- 
quently form  small  masses  admixed  with  fibrin,  and  correspond  with  the 
flakes  of  pus  appreciable  to  the  unaided  eye.  The  syAnal  cord  not  rarely  is 
wholly  unafiected.  At  times  nerve-fibers  in  proximity  to  the  pia  are  in- 
flamed and  swollen.  The  inflammatory  process  may,  however,  invade  the 
septa  that  penetrate  the  spinal  cord  from  the  pia.  The  spincd  nerve-roots 
also  are  but  slightly  involved  in  the  inflammatory  process  in  some  cases, 
while  in  others  degeneration  of  nerve-fibers,  round-cell  accumulations,  and 
vascular  hyperemia  may  be  encountered. 

Htiology. — Purulent  spinal  meningitis  occurs  most  commonly 
in  association  witli  purulent  cerebral  meningitis,  and  the  condition 
is  then  designated  purulent  cerehrosjnnal  meningitis.  This  aifection 
occurs  at  times  in  epidemic  distribution  as  an  independent  infec- 
tious disease,  and  will  receive  detailed  description  in  the  considera- 
tion of  the  infectious  di.seases.  Here  only  those  cases  Avill  be 
discussed  in  which  the  inflammation  is  confined  to  the  soft  mem- 
branes of  the  spinal  cord.  The  affection  under  such  conditions  is 
often  due  also  to  local  causes  and  to  extension  from  adjacent  injlam- 
rnatory  processes.  The  inflammatory  irritant  may  enter  the  spinal 
cord  from  without,  and  therefore  spinal  meningitis  is  at  times 
observed  in  association  with  deep  bed-sores  over  the  sacrum,  with 
suppuration  in  the  pelvic  connective  tissue  as  a  result  of  puerperal 
septicemia,  and  at  times  also  with  pleural  empyema.  Puncture  of 
or  injection  into  the  dural  sac  also  is  capable  of  exciting  purident 
spinal  meninoitis  if  unclean  instruments  or  fluids  containing  bac- 
teria or  irritating  substances  are  employed.  In  the  same  way 
operative  measures,  with  opening  of  the  vertebral  canal,  and  punc- 
tured and  gunshot  wounds  and  traumatism  of  other  kinds  may  give 
rise  to  acute  spinal  meningitis.  At  times  the  disease  is  dependent 
upon    inflammatory  processes  in  the  vertehrse  or  the  spinal  cord. 


INFLAMMATION  OF  SOFT  MEMBRANES  OF  SPINAL  CORD  Q05 

Occasionally  acute  spinal  meningitis  develops  in  the  course  of 
infectious  diseases  (septicemia,  pneumonia,  erysipelas,  typhoid  fever, 
etc.).  Exposure  to  cold  also  is  said  to  be  a  cause,  but  probably  it 
is  only  a  contributory  factor  for  the  infection  of  the  meninges. 

In  the  majority  of  cases  the  excitants  of  the  inflammation  are  bacteria, 
especially  the  Streptococcus  pyogenes  and  the  Staphylococcus  pyogenes 
albus  and  aureus.  The  Meningococcus  intracellularis  has  been  demon- 
strated as  the  cause  of  epidemic  cerebrospinal  meningitis.  Inflammation 
of  the  spinal  meninges  in  consequence  of  purely  chemic  irritation  is  pos- 
sible, but  is  probably  rare. 

Symptoms  and  Diagnosis. — Local  symptoms  are  decisive 
in  the  recognition  of  spinal  meningitis.  The  patient  complains 
frequently  at  first  of  stiffness  and  pain  in  the  vertebral  column,  and 
also  pressure  upon  and  percussion  of  the  vertebrae,  as  well  as  move- 
ment of  the  vertebral  column  in  sitting  erect  and  in  rotation  of 
the  body,  excite  pain.  The  occurrence  of  rigidity  of  the  neck 
(tortiooUis,  ivry-neck)  is  of  especial  diagnostic  importance,  and  is 
dependent  upon  irritation  and  contracture  of  the  muscles  of  the 
neck.  Under  such  circumstances  the  head  may  be  strongly  re- 
tracted, and  it  may  be  impossible  to  flex  it  upon  the  chest.  On 
the  other  hand,  rotation  and  dorsal  flexion  of  the  head  are  not 
interfered  with.  Often  the  muscles  of  the  back  also  are  in  a  state 
of  permanent  contracture,  and  the  vertebral  column  appears  curved 
with  its  convexity  forward,  so  that  the  fist  can  be  easily  placed 
between  the  body  and  the  bed.  Contracture  of  the  abdominal 
muscles  causes  scaphoid  retraction  of  the  abdomen.  Often  a  sense 
of  constriction  about  the  trunk,  and  even  a  painful  girdle-sense,  may 
appear,  and  this  is  indicative  of  irritation  of  the  posterior  nerve- 
roots.  Radiating  pains  in  the  lower  extremities  and  muscular 
twitching  also  are  symptoms  of  irritation  of  tlie  nerve-roots. 
Generally  there  is  cutaneous  hyperesthesia.  The  irritability  of  the 
vasomotor  nerves  also  is  increased,  so  that  even  slight  cutaneous 
irritation  is  sufficient  to  induce  active  and  persistent  reddening  of 
the  skin.  Irritative  manifestations  are  thus  present  throughout  the 
entire  clinical  picture.  Naturally,  these  may  be  followed  by  para- 
lytic phenomena  in  the  progress  of  the  disease.  Muscular  paral- 
ysis develops ;  cutaneous  hyperesthesia  is  replaced  hy  anesthesia; 
paralysis  of  the  bladder  and  the  rectum  appears  ;  the  exaggeration 
of  the  reflexes  is  followed  by  tb.eir  diminution  and  disappearance. 
Pupillary  alterations  occur  often,  inequality  of  the  pupils  with 
especial  frequency.  Little  diagnostic  importance  is  to  be  attached 
to  the  genercd  manifestations.  The  disease  is  almost  always  at- 
tended with  elevation  of  the  bodily  temperature,  although  the  inten- 
sity and  the  type  of  the  fever  are  subject  to  no  definite  rule.  Tlie 
duration  of  the  disease  at  times  extends  over  only  a  few  days,  while 
in  other  instances  the  disorder  is  protracted  over  a  few  weeks,  and 
gradually  assumes  a  rather  chronic  course. 


606  NERVOUS  SYSTEM 

Prognosis. — The  prognosis  of  acute  spinal  meningitis  is  grave. 
The  principal  danger  consists  in  extension  of  the  inflammatory 
process  to  the  cerebral  membranes,  and  death  from  increasing 
cerebral  pressure  or  from  paralysis  of  the  vagus.  Naturally, 
death  may  result,  apart  from  these  conditions,  from  progressive 
exhaustion,  from  paralysis  of  the  bladder  and  urinary  infection,  or 
from  septicemia  in  consequence  of  the  fundamental  disorder.  At 
times  muscular  paralysis  persists  for  a  long  time. 

Treatment. — In  the  first  place,  the  application  of  Chapman's 
ice-bag  to  the  vertebral  column  is  to  be  recommended  in  the  treat- 
ment of  acute  spinal  meningitis.  Internally,  antipyrin  (1.0 — 15 
grains — 4  times  daily)  or  phenacetin  (1.0 — 15  grains — thrice  daily) 
may  be  prescribed  for  the  relief  of  the  pain.  If  this  be  intense, 
subcutaneous  injections  of  morpbin  may  be  necessary.  Scarcely  any 
therapeutic  etfect  will  be  yielded  by  lumbar  puncture.  The  patient 
should  be  placed  at  rest  in  bed,  and  receive  only  liquid  diet,  prefer- 
ably a  milk-diet. 

CHRONIC    INFLAMMATION    OF   THE    SOFT    MEMBRANES    OF 
THE   SPINAL   CORD    (CHRONIC   SPINAL   MENINGITIS). 

Anatomic  Alterations.  —  Chronic  spinal  meningitis  is 
attended  with  connective-tissue  tbickening  of  the  pia  and  the  arach- 
noid. Often  connective-tissue  adhesions  have  formed  between  the 
pia,  the  arachnoid,  and  the  dura.  The  morbid  process  usually 
occurs  in  circumscribed  foci,  is  most  markedly  devek)ped  upon  the 
posterior  aspect  of  the  spinal  cord,  and  involves  with  especial  fre- 
quency the  lumbar  cord,  and  least  commonly  the  cervical  cord. 
At  times  the  pia  particularly  presents  a  brownish  or  blackish  dis- 
coloration, indicative  of  antecedent  hemorrhage.  Calcareous  plates 
not  rarely  form,  particularly  in  the  arachnoid  columns.  The 
cerebrospinal  fluid  is  either  unchanged  or  increased  in  amount. 
At  times  it  appears  slightly  turljid.  On  microscopic  examination 
of  the  spinal  cord  the  unusually  marked  development  of  tlie  pial 
septa  not  rarely  attracts  attention.  Often  nerve-fibers  in  the 
neighborhood  of  the  pia  are  degenerated,  and  at  times  there  is 
complete  marginal  degeneration  of  tlie  white  substance  of  the 
spinal  cord.  The  spinal  nerve-roots  also  often  exhibit  thickening 
of  the  pia,  and  on  microscopic  examination  present  connective- 
tissue  hyperplasia  and  nerve-degeneration. 

Ktiology. — In  the  etiology  of  chronic  spinal  meningitis  the 
same  causative  factors  are  operative  as  in  that  of  acute  meningitis 
(pp.  604  and  605).  At  the  same  time  it  may  happen  that  acute 
inflammation  occurs  at  first,  which  slowly  passes  into  the  chronic 
form,  or,  in  other  instances,  chronic  spinal  meningitis  develops 
independently  from  the  outset.  Si/philis,  alcoholism,  and  chronic 
diseases  of  the  spinal  cord  (chronic  myelitis,  tabes  dorsalis)  par- 


HEMORRHAGE  INTO   THE  SPINAL  MEMBRANES         007 

ticnlarly  are  considered  especially  common  causes  of  chronic  spinal 
meningitis. 

Symptoms  and  Diagnosis. — The  symptoms  of  chronic 
spinal  meningitis  are  identical  with  those  of  acute  meningitis, 
except  for  the  absence  of  fever  and  the  duration  of  the  disease 
often  for  several  years.  Irritative  symptoms  are  present  at  the 
beginning,  and  consist  in  stiffness  and  pain  in  the  vertebral  column, 
rigidity  of  the  neck,  a  girdle-sense,  radiating  'pains  in  the  lower 
extremities,  paresthesias,  muscidar  twitching  and  contractures, 
cutaneous  hyperesthesia,  and  exaggeration  of  the  reflexes.  After 
a  time  2:>aralysis  develops  if  the  spinal  cord,  and  particularly  the 
nerve-roots,  are  degenerated.  The  muscles  are  rather  paretic  than 
paralytic,  and  undergo  degenerative  atrophy  and  exhibit  degener- 
ative electric  reaction.  The  reflexes  become  enfeebled  or  dis- 
appear. Cutaneous  anesthesia  develops,  and  frequently  paralysis 
of  the  bladder  and  the  rectum  occurs,  with  the  development  of 
urinary  infection,  bed-sores,  and  septicemia.  At  times  the  dis- 
order assumes  an  acute  character.  By  extension  of  the  inflam- 
matory process  to  the  meninges  of  the  brain  and  the  medulla 
oblongata  death  may  result  from  excessive  cerebral  pressure  or 
from   respiratory  or  cardiac  paralysis. 

Prognosis. — Recovery  from  chronic  spinal  meningitis  is  not 
impossible.  Nevertheless,  the  prognosis  is  serious,  particularly  in 
the  presence  of  paralysis  of  the  bladder  and  the  rectum. 

Treatment. — Causal  treatment  is  indicated  when  there  is  a 
history  of  alcoholism  or  of  syphilis.  In  the  case  of  drunkards 
alcohol  should  be  withdrawn,  and  syphilitics  should  be  treated 
wdth  inunctions  of  mercurial  ointment  and  the  internal  adminis- 
tration of  potassium  iodid.  Symptomatically  the  use  of  warm  baths 
(28°  R.— 35°  C— 95°  F.)  should  be  recommended.  Saline  baths 
also  may  be  employed.  Mercurial  inunctions  and  potassium  iodid 
also  have  been  employed  in  non-syphilitic  cases,  but  yield  no 
definite  results.  AMien  muscular  paralysis  develops  resort  should 
be  had  to  massage  and  electricity. 

HEMORRHAGE  INTO  THE  SPINAL  MEMBRANES. 

lEtiology. — Hemorrhage  into  the  membranes  of  the  spinal 
cord  is  only  of  subordinate  clinical  significance.  It  occurs  at  times 
as  the  result  of  traumatism,  and  not  alone  after  punctured,  incised 
and  gunshot  wounds  and  fractures  and  luxations  of  the  vertebrae, 
but  also  after  concussion,  powerful  expulsive  efforts,  and  heavy 
lifting.  It  is  often  a  sequel  of  circulatory  disturbances.  It  occurs 
particularly  in  conjunction  with  convulsive  disorders  (eclampsia, 
epilepsy,  tetanus).  Chronic  diseases  of  the  heart  and  of  the  res- 
piratory organs  also  at  times  cause  meningeal  hemorrhage,  w-hich 
occasionally  accompanies  inflammation  of  the  meninges,  the  spinal 


608  NERVOUS  SYSTEM 

cord,  or  the  vertebral  column.  Xot  rarely  meningeal  hemorrhage 
occurs  in  the  course  of  infectious  diseases,  apparently  because  the 
vessels  become  abnormally  })ermeable  to  the  blood-corpuscles  as 
the  result  of  the  infective  process.  Sometimes  blood  passes  from 
the  intermeningeal  spaces  of  the  brain  into  the  corresponding 
spaces  of  the  spinal  cord.  It  may  also  happen  that  an  aortic 
aneurysm  ruptures  into  the  vertebral  canal  and  pours  its  contents 
into  the  intermeningeal  space.  A  similar  result  has  been  observed 
also  from  rupture  of  tlie  vertebral  artery  and  the  spinal  artery. 
At  times  it  is  not  possible  to  discover  a  cause  for  the  condition — 
cri/ptor/enetic  meningeal  heniorrhage. 

Anatomic  Alterations. — Meningeal  hemorrhage  can  be 
readily  recognized,  and  in  accordance  with  its  age  presents  a 
bright-red  or  a  brownish-red  appearance.  In  size  it  varies  from 
punctate  and  barely  visible  spots  to  extravasations  that  may 
extend  throughout  the  entire  length  of  the  spinal  cord.  Should 
absorption  take  place,  brownish  pigment-spots,  subsequently  be- 
coming black,  often  persist.  In  accordance  with  the  seat  of  the 
hemorrhage  several  varieties  are  distinguished.  EpuJural  hemor- 
rhage occurs  upon  the  outer  aspect  of  the  dura,  particularly  in  the 
fatty  connective  tissue  that  separates  the  dura  from  the  inner 
aspect  of  the  vertebral  canal.  Subdural  hemorrhage  (formerly 
designated  also  arachnoid)  occurs  in  the  narrow,  capillary  space 
between  the  dura  and  the  arachnoid.  In  this  category  belongs  the 
internal  hemorrhagie  pachymeningitis  described  on  p.  603.  Sub- 
arachnoid hemorrhage  is  not  rarely  the  result  of  extravasation  of 
blood  into  the  corresponding  portion  of  the  brain,  and  together  with 
cerebrospinal  fluid  may  be  present  in  the  interstices  of  the  arachnoid. 
Subpial  hemorrhage  can  be  conceived  as  resulting  only  from  dis- 
placement of  the  pia  from  the  structure  of  the  cord  by  the  blood. 

Symptoms  and  Diagnosis. — The  sudden  onset  and  the 
predominance  of  irritative  symptoms  are  distinctive  of  meningeal 
hemorrhage.  Naturally,  these  features  can  be  expected  only  if 
the  extravasation  of  blood  is  sufficiently  large  to  cause  irritation 
of  the  meninges  and  the  spinal  nerve-roots.  Hemorrhages  of 
smaller  amount  may  be  unattended  with  symptoms  and  fail  of 
recognition  during  life.  At  times  a  sense  of  drawing  and  other 
unusual  sensations  in  the  vertebral  column  have  preceded  the 
occurrence  of  the  hemorrhage  for  a  day  or  even  longer,  as  jwo- 
dromes.  The  occurrence  of  a  hemorrhage  of  considerable  amount 
is  attended  with  severe  pain  in  tlie  vertebral  column,  whose  seat 
corresponds  with  that  of  the  hemorrhage,  and  is  probably  depen- 
dent upon  the  sudden  distention  of  the  meninges.  The  patient  is 
conscious  of  stiffness  and  generally  of  increase  in  the  pain  on  move- 
ment of  the  vertebral  column.  Should  the  hemorrhage  be  seated 
in  the  cervical  cord,  rigidity  of  the  neck  may  develop.  Irritation 
of  posterior  nerve-roots  may  cause  a  girdle-sense  about  the  trunk, 


NEOPLASMS  OF  THE  SPINAL  MENINGES  609 

and  often  also  radiating  pains  in  the  lower  extremities.  Pares- 
thesise,  hyperesthesia,  muscular  twitching  and  contractures  are  not 
rarely  present.  Hemorrhage  of  sufficient  extent  is  capable  of 
causing  paralysis  of  spinal  nerve-roots  and  the  spinal  cord  by 
compression.  Under  such  circumstances  cutaneous  anesthesia, 
muscular  paralysis  with  degenerative  atrophy  and  degenerative 
electric  reaction,  enfeeblement  or  abolition  of  reflex  movement,  and 
paralysis  of  the  bladder  and  the  rectimi  may  develop.  The  distri- 
bution of  the  manifestations  described  depends  up(ni  the  seat  and 
the  extent  of  the  hemorrhage.  In  contradistinction  from  spinal 
hemorrhage,  meningeal  hemorrhage  is  distinguished  by  the  pres- 
ence of  irritative  symptoms  at  the  beginning. 

Prognosis. — The  prognosis  should  be  guarded.  Danger  re- 
sides in  the  fact  that  hemorrhage  at  a  high  level  may  injure  the 
nerve-roots  in  the  medulla  oblongata.  Bulbar  symptoms  (disturb- 
ance in  articulation  and  in  deglutition)  develop,  and  in  connection 
with  which  paralysis  of  the  vago-accessory  nerve  may  give  rise  to 
a  fatal  termination  through  paralysis  of  respiration  or  of  the  heart. 
At  times  meningeal  hemorrhage  may  be  complicated  by  menhigith, 
with  its  serious  dangers.  Should  paralysis  of  the  bladder  and  the 
rectum  develop,  the  danger  of  urinary  infection,  bed-sores,  and 
septicemia  arises.  At  times  ^9ara?2/s?s  remains  permanently.  Com- 
plete recovery  is,  however,  by  no  means  impossible. 

Treatment. — The  application  of  a  Chapman  ice-bag  to  the 
vertebral  column  should  be  directed;  a  diet,  principally  of  milk,  be 
prescribed  ;  the  use  of  coffee,  wine,  tea,  and  alcoholics  be  interdicted  ; 
and  free,  easy  evacuation  of  the  bowels  be  provided  for.  Severe  pain 
should  be  relieved  by  phenacetin  (1.0 — 15  grains — thrice  daily), 
antipyrin  (1.0 — 15  grains — four  times  daily),  or  subcutaneous  in- 
jection of  morphin.  Persistent  paralysis  will  require  massage, 
which  is  to  be  preferred  to  the  application  of  electricity.  After 
the  disappearance  of  all  irritative  symptoms  baths  may  be  of  ad- 
vantage, particularly  saline  baths. 

NEOPLASMS  OF  THE  SPINAL  MENINGES* 

Anatomic  Alterations. — Xeoplasms  of  the  spinal  meninges 
arise,  as  a  rule,  from  the  dura  mater,  and  generally  are  spherical  in 
shape.  They  vary  in  size,  although  they  rarely  exceed  5  cm.  in 
length.  Fibromata,  lipomata,  myomata,  sarcomata,  psammomata, 
melanomata,  neuromata,  tuberculomata,  gummata,  enchondromata, 
osteomata,  carcinomata,  and  lymphangiomata  have  been  observed. 
By  reason  of  the  small  size  of  the  vertebral  canal,  extensive  de- 
velopment of  the  neoplasm  is  possible  only  by  penetration  of 
the  new-growth  through  the  intervertebral  foramina  and  prolifer- 
ation externally,  or  by  compression  of  the  spinal  cord  and  the 
nerve-roots.     At  times  neoplasms  have  formed  a  deep  excavation 

39 


610  NERVOUS  SYSTEM 

in  the  spinal  cord,  while  in  other  instances  the  cord  and  adjacent 
nerve-roots  are  flattened.  As  a  result  of  the  compression  soften- 
ing of  the  spinal  cord  may  readily  result.  Below  and  above  the 
point  of  compression  secondary  degeneration  occurs  after  a  time  : 
above  in  the  column  of  Goll,  the  lateral  cerebellar  tracts,  and  the 
bundle  of  Gowers,  and  below  in  the  lateral  pyramidal  tracts. 

Ktiology. — Syphilis  is  definitely  known  as  the  cause  for  gum- 
mata,  and  tuberculosis  for  tuberculomata.  Otherwise,  nothing  is 
kno\vu  with  regard  to  the  etiology.  Traumatism,  pregnancy,  and 
the  puerperium  are  further  included  among  the  causative  condi- 
tions. Malignant  neoplasms  (sarcoma,  carcinoma)  at  times  arise 
by  metastasis  from  antecedent  neoplasms  in  other  organs.  Ex- 
perience has  shown  that  men  beyond  tJie  fortieth  year  of  life  are 
most  commonly  attacked. 

Symptoms  and  Diagnosis. — Neoplasms  of  the  spinal  men- 
inges give  rise  to  morbid  manifestations  only  if  at  first  they  irri- 
tate the  membranes,  and  subsequently  cause  paralysis  as  a  result 
of  excessive  compression  of  the  spinal  cord  or  the  spinal  nerve- 
roots.  The  irritative  symptoms  are  the  same  as  those  that  have 
been  mentioned  in  previous  sections  :  Pain  and  a  sense  of  stiffness 
in  the  vertebral  column,  a  sense  of  constriction,  shooting  pains  in 
the  extremities,  hyperesthesia,  paresthesia,  muscular  twitching 
and  contracture.  In  the  presence  of  spinal  pressure-paralysis  the 
clinical  picture,  in  accordance  with  the  existing  conditions,  may 
be  that  of  total  transverse  lesion  of  the  spinal  cord  (paraplegia, 
para-anesthesia,  exaggeration  of  the  reflexes,  paralysis  of  the  blad- 
der and  the  rectum),  or  that  of  a  unilateral  lesion  of  the  cord,  or 
a  circumscribed  injury  of  the  cord.  In  the  last  event  motor  or 
sensory  paralysis  will  predominate  accordingly  as  the  tumor  com- 
presses the  spinal  cord  from  in  front  or  behind.  Compression  of 
the  nerve-roots  also  will  cause  paralysis  of  motility  and  sensibility. 
It  is  distinctive  for  the  paralyzed  muscles  to  undergo  rapid  degen- 
erative atrophy,  with  degenerative  electric  reaction  and  abolition 
of  reflex  movement. 

The  duration  of  meningeal  neoplasms  extends  at  times  over  sev- 
eral years.  The  dangers  consist  in  a  complicating  meningitis,  in 
excessive  exhaustion,  in  the  presence  of  paralysis  of  the  bladder 
and  the  rectum,  in  cystitis  and  urinary  infection,  and  in  bed-sores 
and  septicemia. 

The  diagnosis  of  neoplasms  of  the  spinal  meninges  is 
attended  with  unusually  great  difficulty.  There  is  generally  a 
gradual  development  of  the  symptom-complex  of  meningeal  irri- 
tation. The  presence  of  neoplasms  in  other  organs  is  a  matter  of 
great  importance,  thus  rendering  probable  the  existence  of  meta- 
static new-growths.  In  contradistinction  from  tumors  of  the 
spinal  cord  itself,  irritative  symptoms  predominate  in  the  presence 
of  spinal  neoplasms.     The  nature  of  the  neoplasm  is  generally  in- 


NEOPLASMS  OF  THE  SPINAL  MENINGES  611 

volved  in  doubt,  except  in  the  case  of  metastatic  growths.  With 
regard  to  the  seat  of  the  disease,  local  changes  in  the  vertebral  col- 
umn and  the  distribution  of  the  symptoms  are  decisive.  Tumors 
of  the  Cauda  equina  not  rarely  are  attended  with  circumscribed 
cutaneous  anesthesia  of  the  perineum,  the  scrotum,  the  penis,  and 
the  posterior  aspect  of  the  thigh.  In  addition,  paralysis  of  vari- 
ous muscles  and  the  bladder  and  the  rectum,  and  abolition  of  re- 
flex movement,  occur. 

Prognosis  and  Treatment. — Although  meningeal  tumors 
have  recently  been  successfully  removed  by  surgical  means  after 
opening  the  vertebral  column,  the  prognosis  is  nevertheless  serious, 
in  the  majority  of  cases.  Causal  therapy  should  be  employed  in 
cases  of  syphilis  (mercurial  inunctions,  internal  administration 
of  potassium  iodid). 

In  a  few  rare  cases  cysticerci  and  echinococci  have  been  found  in  the 
spinal  meninges,  and  the  latter  have  been  removed  by  operation. 


INDEX  TO  VOLUME  I. 


Abdominal  dropsy,  382 
muscles,  peripheral  paralysis  of,  504 
spasm  of,  512 
Acephalocysts,  352 
Acoria,  240 
Addison's  disease,  468 

treatment,  471 
Adrenal  bodies,  diseases  of,  468 
Affrictus  perieardiacus,  54 
Ageusia,  531 
Agonal  edema,  124 
Albumin  in  urine,  determination,  390 
Albuminoraeter,  Esbach's,  390 
Albuminuria,  387 
accidental,  388 
causes,  391 
false,  388 

hematogenous,  388 
in  pneumonia,  136 
nephrogenous,  388 
pathologic,  388 
persistent,  388 
physiologic,  387 
renal,  388 
tests  for,  388 
Boedecker's,  389 
boiling-nitric-acid,  388 
Galippe's,  389 
Heller's,  389 
Panum's,  389 
transitory,  388 
treatment,  392 
Albumoses  in  urine,  389 
Alcoholic  paralysis,  539 
Amaurosis,  uremic,  397 
Amoeba  coli,  292 
Anachlorhydria,  240 
Anacidity,  240 
Anadenia,  gastric,  214 
Anemia,  bothriocephalus,  297 
brickmakers',  311 
miners',  311 
tunnel,  311 
Anesthesia,  525 
cutaneous,  525 
infectious,  527 
paresthesia  with,  528 
refrigeratory,  527 
toxic,  527 


Anesthesia,  cutaneous,  traumatic,  527 
treatment,  528 
vasomotor,  527 
dolorose,  528 
trigeminal,  528 

neuroparalytic    ophthalmia    with, 
529 
Aneurysm,  wall  of,  66 
Angina,  184 

circumscribed,  187 
complications,  187 
diffuse,  187 
lacunar,  187,  188 
parenchymatous,  187,  189 
pectoris,  63 
phlegmonous,  187 
superficial,  186,  188 
treatment,  189 
Anguillula  intestinalis,  315 

stereo ralis,  315 
Ankylostomiasis,  311 

treatment,  314 
Ankylostomum  duodenale,  311 
Anosmia,  529 

Anterolateral  remnant,  546 
Ante-stomach,  199 

Anthrax,  pulmonarv,  and  bronchiecta- 
sis, 109 
Aorta,  aneurysm  of,  65 
diagnosis,  70 
neuralgia  in,  69 
paralysis  from,  69 
pressure-phenomena,  69 
rupture,  69 
symptoms,  67-70 
treatment,  70 
varieties,  65 
diseases  of,  65 
embolism  of,  72 

gangrene  and,  72 
isthmus  of,  constriction  and  occlusion 
of,  71 
Aortic  insufficiency  with  valvular  dis- 
ease, 37 
obstruction  with  valvular  disease,  38 
Ape-hand,  496 
Aphonia,  spastic,  94 
Appendicitis,  257 
complications,  261 

613 


614 


INDEX  TO    VOLUME  I. 


Appendicitis,  diagnosis,  263 

symptoms,  260 

treatment,  264 
Arachnitis,  603 
Arachnoid  hemorrhage,  608 
Arm   and   brachial   plexus,   nerves  of, 
paralysis  of,  498 

external  rotators  of,  paralysis  of,  504 

internal  rotators  of,  paralysis  of,  503 
Arsenical  paralysis,  538 
Arytenoid  muscles,  paralysis  of,  90 
Ascaris  lumbricoides,  301 

mystax,  303 
Ascites,  382 

cachectic,  382 

chylous,  383 

fatty,  383 
■   hypostatic,  382 

treatment,  385 
Aspermatism,  464 
Asthma,  cardiac,  30 

dyspeptic,  215,  236 

hay-,  78 
Asthma-cigarets,  117 
Asthma-crystals,  115 
Asthma-spirals,  115,  116 
Ataxia,  Friedreich's,  592 

hereditary,  592 
spinal  cord  in,  595 

locomotor,  572.     See  also   Tabes  dor- 
salis. 

origin  of,  577 
Atrophy,  spinal   progressive   muscular, 
588 
syringomyelia  and,  592 
treatment,  592 
Auricle,  muscles  of,  paralysis  of,  482 
Axillary  nerve,  paralysis  of,  498 
Azoospermia,  464,  465 

BAcrLLl   of   diphtheria   and    fibrinous 

rhinitis,  77 
Back,  muscles  of,  peripheral   paralvsis 

of,  504 
Bacteria    of    bronchopneumonia,    125, 

126 
Bacteriuria,  457 

Balantidium  s.  Paramcecium  coli,  293 
Balsamics  in  bronchial  catarrh,  103 
Biernier's  change  in  pitch,  165 
Biliary  calculi,  362 

passages,  carcinoma  of,  361 
catarrii  of,  357 
diseases  of,  357 
echinococci  in,  352 
parasites  in.  361 
purulent  inflammation  of,  359 
sand, 362 
Bladder,  detrusor  of,  paralysis  of,  462 
sphincter  of,  paralysis  of,  462 
urinary,  abscess  in,  450 


Bladder,  urinary,  carcinoma  of,  455 
desquamative  catarrh  of,  451 
diseases  of,  448 
foreign  bodies  in,  457 
hyperesthesia  of,  460 
hypertrophy  of,  450 

treatment,  455 
inflammation    of,    448.      See    also 

Urocystitis. 
neuroses  of,  458 
paralysis  of,  461 
parasites  of,  457 
purulent  catarrh  of,  451 
spasm  of,  460 
Blepharospasm,  508 
Blood  in  urine,  392 
Blood-shadows,  393 
Boedecker's  test  for  albuminuria,  389 
Boiling  in  chest,  124 
Bostock's  catarrh,  77 
Bothriocephalus  latus,  293,  297 
Bothriocephalus  anemia,  297 
Bowel,  intussusception  of,  271 
nomenclature,  272 
treatment,  274 
ob.struction  of,  275 

effect  on  general  condition,  280 
diagnosis,  278 
symptoms,  278 
treatment,  283 
stenosis  of,  275 
diagnosis,  278 
symptoms,  278 
treatment,  283 
Box-note,  114 
Brachial  plexus  and  arm,  paralysis  of 

nerves  of,  498 
Bracht-Rombeig's  symptom,  539,  576 
Bradycardia,  paroxysmal,  63 

with  fat  heart,  30" 
Brain,  diseases  of,  hiccough  and,  512 
Brickmakers'  anemia,  311 
Bronchi,  diseases  of,  96 
Bronchial  asthma,  113 
treatment,  116 
catarrh,  96 

bacteria  and,  97 
dry,  98 
moist,  98 
rales  in,  98 
symptoms,  98-101 
treatment,  102 
coagulum,  104 
constriction.  111 
croup,  103 
dilatation,  106 

treatment,  110 
ulcers.  97 
Bronchiectasis,  106 
complications,  109 
diagnosLs,  108 


INDEX  TO    V0LU3IE  I. 


615 


Bronchiectasis,  symptoms,  108 

treatment,  110 
Bronchiolitis,  100 

and    alveolar    emphysema   of    lungs, 
118 
Bronchitis,  fibrinous,  103 
treatment,  106 

putrid,  100 
Bronchoblennorrhea,  100 
Bronchopneumonia,  125 
Bronchorrhea.  100 
Bronchostenosis,  111 
Bronze-disease,  469 
Bubbling  murmurs,  166 
Bucardia,  27 
Bulimia,  240 
Burdach's  column,  546 

Cacosmia,  530 
Cadaveric  position,  91 
Calculi,    biliary,   362.      See   also    Gall- 
stones. 

carbonate-,  441,  446 

cvstin-,  442,  446 

indigo-,  442,  446 

mulberry-,  363,  441, 446 

oxalate-*  441,  446 

phosphatic,  441,  446 

renal,  441 

treatment,  446 

uratic,  441,  446 

xanthin-,  442,  446 
Caput  Medusse,  335 
Carbon-dioxid  narcosis,  127 
Carcinosis,  miliary,  150 
Cardia,  carcinomata  of,  224 

spasm  of,  236 
Cardiac  insufficiency,  17.  See  also  Myo- 
cnrclium,  vjeakness  of. 

intermittency,  63 

neuroses,  61 
Cardiorhexis,  34 
Cardiospasm,  236 

Catarrh,  acute  gastro-intestinal,  in  in- 
fants, 247 
treatment,  250 

autumnal,  77 

Bostock's,  77 

calculus-forming,  363 

drunkards',  212 
Cecum,  inflammation  of,  257.     See  also 

T)/phlitis. 
Cell,  heart-failure,  20 
Cercomonas  coli,  293 

intestinalis,  293 
Cerebellar  tract,  lateral,  545 
Cerebral  arteries,  embolism  of,  43 

nerves,  multiple  paralysis  of,  490 
Cerebrospinal  sclerosis,  multiple,  560 
nystagmus  in,  562 
treatment,  563 


Cervical  muscle,  spasm  of,  511 
Cestodes,  293.     See  also  Tapeworms. 
Cheyne-Stokes  breathing   in  fat  lieart, 

30 
Chlorosis,  tropical,  311 
Cholangitis,  catarrhal,  357 

purulent.  359 
Cholecystitis,  catarrhal,  357 

purulent,  359 
Choledoch  duct,  carcinoma  of  mouth  of, 

3G1 
Cholelithiasis,  362.     See  also  Gall-stones. 
Cholemia,  320,  340 
Cholera  nostras  s.  europsea,  243 
Chorditis,  tuberous,  83 

vocalis  hypertrophica  inferior,  83 
Chylopericardium,  60 
Chylothorax,  170 
Cicatrix,  apoplectic,  550 
Circulatory  organs,  diseases  of,  17 
Cirrhosis,  portal.  333 
Cirsomphalos,  335 
Clarke's  column,  543 
Claw-hand,  496,  497 
Coccygodynia,  524 
Coccvx,  neuralgia  of,  524 
Colic,  hepatic.  362 

intestinal,  291 

mucous,  255 

renal,  444,  445 
treatment,  447 
Column  of  Burdach,  546 

of  Clarke,  543 

of  GoU,  546 

of  Gowers,  546 
Compensation,  derangement  of,  venous 

stasis  with,  42 
Compression-myelitis,  569,  598 
Compression-paralysis,  spinal,  567 
general  paralysis  with,  569 
treatment,  571 
Contact-sensibility,  testing  of,  526 
Contraction,  fascicular  muscular,  591 
Contraction-formula,    normal,    reversal 

of,  473 
Convulsions,  uremic,  397 
Coprostasis,  276 
Cor  adiposum,  29 

bovinum,  27 

hirsutum,  53 
Coryza,  73 

complications,  74 

hay-,  78 

treatment,  76 
Cough  in  bronchial  catarrh,  99 

laryngeal,  95 
Cramps,  513 

Crico-arytenoid  muscles,  posterior  paral- 
ysis of,  90 
Cricothyroid  muscles,  paralysis  of,  92 
Croup,  bronchial,  103 


616 


INDEX  TO    VOLUME  I. 


Crural   nerve,   peripheral   paralysis  of, 

505 
Crutch-palsy,  492 
Cutaneous  sensibility,  525 
Cyanosis,  congenital,  46 
Cysticercus  cellulosse,  293 
Cystoplegia,  461 
Cystospasm,  460 

Damoisean's  curves,  155 
Dextrocardia,  34 
Diaphragm,  paralysis  of,  491 

spasm  of,  511 
Diarrhea,  dentition,  248 

fatty,  255 

nervous,  290 

summer,  of  infants,  247 
Diarrhcea  ablactatorum,  248 
Digestive  organs,  diseases  of,  175 
Digitalis-leaves  for  cardiac  insufficiencv, 

23 
Diplegia,  facial,  485 
Diplococcus   pneumoniae  s.  lanceolatus. 

129 
Dittrich  plugs,  101 

Dorsal  muscle,  broad,  paralysis  of,  503 
Dro[)sy,  abdominal,  382 
Drum-stick  fingers,  46,  110 
Drunkards'  catarrli,  212 
Drunkards,  morning  vomiting  of,  214 
Duodenitis,  acute  catarrhal,  244,  245 

chronic  catarrhal,  255 
Duodenum,  round  ulcer  of,  266 
Dura  mater  and  spinal  column,  relation 
of,  541 
spinal,  inflammation  of,  601 
Dyspepsia,  nervous,  241 
Dystopia  ventriculi,  233 

EcHixococcrs-CYSTS,  sterile,  352 
Eclampsia,  uremic.  397 
Electric-sense  of  skin,  testing  of,  526 
Empyema  pleurae  necessitatis,  157 
Endocarditis.  47 
chronic,  36 
contracting,  47 
cryptogenetic,  47 
fetal,  and  heart-disease.  46 
recurrent  contracting,  47 
ulcerative,  47 

and  puerperal  fever,  47 
and  typhoid  fever,  49 
treatment,  49 
verrucose,  47,  49 
and  rheumatism,  50 
and  scarlet  fever,  50 
Endocardium,  diseases  of,  35 

inflammation  of,  47.      See  also  Endo- 
cnrclitif^. 
Enormitas  cordis,  27 
Enteralgia,  nervous,  291 


Enteritis,  membranous,  255 
Enteroptosis,  288 
Enterorrhagia  of  newborn,  288 
Enterostenosis,   275.      See    also    Bowel, 

sleiiosis  of. 
Enuresis,  diurnal,  458 

nocturnal,  458 
Epidural  hemorrhage,  608 
Epigastrium,  restless  movements  in,  23i) 
Erb's  paralysis  of  brachial  plexus,  499 

supraclavicular  point,  499 
Ergotism,  539 

Ergot-poisoning,  paralysis  from,  539 
Eructation,  211 
nervous,  235 
Esbach's  albuminometer,  390 

reagents,  389 
Esophagism,  204 
Esophagitis,  catarrhal,  200 

phlegmonous,  201 
Esophagomalacia,  202 
Esophagus,  carcinoma  of,  191 
complications,  195 
diagnosis,  196 
paralvsis    of     recurrent    larvngeal 

from,  193 
treatment,  196 
catarrh  of,  2U0 
dilatiition  of,  199 
dimensions  of,  194 
diseases  of,  191 
diverticula  of,  197 
pulsion-,  198 
traction-,  198 
paralysis  of,  203 
peptic  ulcer  of,  201 
softening  of,  202 
spasm  of.  204 

spontaneous  rupture  of,  202 
stenosis  of,  196 

and  carcinoma,  192,  193 
thrush  of,  203 
Esthesiometer,  526 
Eiat  mamelonne,  213 
Expectorants,  102 

Exploratory  puncture,  apparatus,  160 
Extremities,  arteries  of,  embolism  of,  43 
Evebrow,  corrugator  muscle  of,  paraly- 
sis of,  481 
Eyelids,  orbicular  muscle  of,  paralvsis 
of,  481 

Face,  muscles  of,  spasm  of,  508 

paralysis  of  muscles  of,  478 
Facial  nerve,  diagram   of  distribution, 
4.^7 
paralysis  of,  477 
diagnosis,  486 
treatment,  488 
Fasciculus,  anterolateral,  546 
Fecal  concretions,  true,  259 


INDEX  TO    VOLUME  I. 


617 


Fecal  concretions,  false,  258 
Finger,  drumstick,  AQ,  110 
Fistula,  bimucous  intestinal,  281 

pulmonary,  166 
Four-glass  test,  210 
Fremissement  cataire,  36 
Fremitus,  bronchial,  98 
Friedreich's  ataxia,  592 
Fright-paralysis,  601 

Gat-ippe's  picric-acid  test,  389 
Gall-bladder,  carcinoma  of,  361 
dropsy  of,  360 
empyema  of,  359 
Gall-stones,  362 
facetted,  363 
treatment,  366 
Ganglion-cells  of  anterior  horns,  disease 
of,  582 
in  adults,  inflammation  of,  586 
pigmentary  degeneration  of,  588 
Gangrene  and  embolism  of  aorta,  72 
from  perichondritis  of  larynx,  88 
Gastralgia,  nervous,  238 
Gastrectasis,  227 
treatment,  231 
Gastric  catarrh,  acute,  210 
chronic,  212 

treatment,  215 
hypertrophic,  213 
juice,  digestive  power  of,  206 
hydrochloric  acid  in,  207,  209 
hypersecretion  of,  241 
lab-ferment  in,  210 
pepsin  in,  209 
Gastritis,  chronic  atrophic,  213 
cystic,  214 
polypous,  213 
phlegmonous,  216 
purulent,  216 
Gastro-intestinal  catarrh,   acute,  in  in- 
fants, 247 
treatment,  250 
Gastroptosis,  229,  233 
Gastrosuccorrhea,  241 
Gastroxynsis,  242 

Genito-urinary  organs,  diseases  of,  387 
Glans  penis,  neuralgia  of,  524 
Gliomatosis,  565 
Glomerulonephritis,  404 
Glossoplegia,  489 
Glottis,  edema  of,  85 

disease  of  larynx  and,  86 
spontaneous,  86 
spasm  of,  93 
phonatory,  94 
rachitis  and,  94 
Gluteal  nerves,  peripheral  paralysis  of, 

506 
Gmelin's  test  for  biliary  coloring-matter, 
319 


"  Golden  vein,"  286 
GoU,  column  of,  546 
Gowers'  column,  546 
Gray  matter  of  spinal  cord,  541 
Giinsburg's   phloroglucin-vanillin  solu- 
tions, 207 
Gustatory  nerve,  disease  of,  530 

Hagen-Brandt's    formula    to     abort 

acute  coryza,  76 
Hand,  ape-,  496 

claw-,  496,  497 
Hay-asthma,  78 
Hay-coryza,  78 
Hay-fever,  77 

Head,  muscles  of,  spasm  of,  511 
Heart,  acquired  valvular  disease  of,  35 
cardiac     manifestations   with, 

37 
diagnosis,  43 
embolic  alterations,  42 
spontaneous  recovery,  44 
symptoms,   37-43 
treatment,  45 
venous  stasis  with,  42 
beer-,  Munich,  28 
chronic  aneurysm  of,  after  mycocar- 

ditis,  33 
dilatation  of,  24 

acute,  blood-pressure  and,  25 
and  cardiac  insufliciency,  27 
and  pericarditis,  57 
diminished     resistance     of    heart- 
muscle  and,  24 
treatment,  28 
echinococcus  of,   34 
fat,  29 

anemic,  30 
cachectic,  30 
plethora  and,  30 
hypertrophy  of,  28 

'toxic,  29" 
new-growths  of,  33 
0X-,  27 

right-sided,  34 
rupture  of,  34 
thrombosis  of,  51 
villous,  52 
Heartburn,  211 
Heart-disease,  congenital  45 
Heart-failure  cells,  20 
Heart-murmurs,  localization,  43 
Heart-pain,  nervous,  63 
Hellei-'s  nitric-acid  test,  389 

test  for  hematuria,  393 
Helminthiasis,  intestinal,  292 
Hematemesis  of  newborn,  288 
Hematinuria,  396 
Heraatomyelia,  548 
Hematomyelitis,  548,  553 
Hematoporphyrinuria,  396 


618 


INDEX  TO    VOLUME  I. 


Hematuria,  392 

Heller's  test,  393 
Hemiplegia,  iacial,  485 
Hemoglobinuria,  392,  394 
Hemopericai'diiim,  60 
HemopneuDiopericardium,  58 
Hemopneumotliorax,  162 
Hemoptysis   and    fibrinous    bronchitis, 

105 
Hemorrhoidal  nodules,  inflammation  of, 

286 
Hemorrhoids,  284 

blind,  286 

mucous,  286 

treatment,  287 
Hemothorax,  170 
Hepatic  artery,  aneurysm  of,  370 

embolism  of,  43 
Hepatitis,  chronic  interstitial,  331.    See 
also  Liver,  cirrhosis  of. 

suppurative,  327 
treatment,  330 
Hepatoptosis,  355 
Herpes  with  pneumonia,  137 
Hiccough,  511 

Horns,   anterior,  ganglion-cells  of,   dis- 
ease of,  582 
in  adults,  inflammation  of  ganglion- 
cells  of,  586 
Hunger,  disorders  of  sense  of,  240 
Hydromyelia,  564 
Hydronephrosis,  435 

and  pyelitis,  440 

partial,  436 

treatment,  438 

varieties,  437 
Hydropericardium,  59 
Hydropneumopericardium,  58 
Hydropneumothorax,  162 

diagnosis,  166 

encapsulated,  162,  167 

subphrenic,  167 

treatment,  168 
Hydrothorax,  169 
Hypaciditv,  208,  240 
Herperacidity,  208,  209,  240 
Hyperacusis,  Willisian,  482 
Hyperchlorhydria,  240 
Hypergeusia,  531 
Hyperkinesis,  507 
Hy parosmia,  529 

Hypertropliy,  cardiac,  eccentric,  24 
Hypochlorhydria,  240 
Hypogeusia,  531 
Hypoglossal  nerve,  paralysis  of,  489 

spasm,  510 
Hyposmia,  529 

Icterus,  315.     See  also  Jaundice. 
viridis,  324 
in  cardiac  insufficiency,  20 


Ileocolitis,  244 

Ileus,  275.     See  also  Bowel,  obstructixm  of. 

paralytic,  277 
Iliopsoas  muscle,  paralysis  of,  505 
Impotence  in  male,  463 
Infants,  acute  gastro-intestinal  catarrh 
in,  247 
treatment,  250 
fatty  liver  in,  342 

feeding  of,  with  milk  substitutes,  252 
Inferior  oblique  muscle  of  head,  spasm 

of,  511 
Intention-tremor,  561 
Intestinal  crises,  291 
Intestine,  animal  parasites  of,  292 
atony  of,  289 
carcinoma  of,  267 
treatment,  270 
catarrli  of,  acute,  242 

symptoms  and  diagnosis,  244 
treatment,  246 
chronic,  252 
treatment,  256 
diseases  of,  242 

hemorrhage  of,  in  newborn,  288 
nervous  spasm  of,  290 
neuroses  of,  289 
motor,  289 
sensory,  290 
peristaltic  unrest  of,  290 
polypi  of,  270 
protozoa  in,  292 

relaxation  of  muscular  coat  of,  289 
sarcoma  of,  270 
worms  of,  293 
Intussusception,  271 
Intussusceptum,   271 
Intussuscipiens,  271 
Invagination,  271 
Isthmus  aortse  persistens,  71 

of  aorta,  constriction  and  occlusion  of, 
71 
Itching-sense,  testing  of,  526 

Jaffe's  test  for  indican  in  urine,  281 
Jaundice,  315 

catarrhal,  358 

cutaneous,  318 

diagnosis,  321 

difi'usive,  316 

due  to  pjeiochromia,  316 

due  to  polycholia,  3i6 

gastroduodenal,  317,  358 

hepatogenous,  316 

hvpertrophic  cirrhosis  of  liver  with, 
337 

menstrual,  357 

of  mucous  membranes,  318 

toxic,  317 

treatment,  322 
Jejunitis,  244,  246 


INDEX  TO    VOLUME  L 


619 


Kidneys,  absence  of,  432 
adenoma  of,  425 
amyloid,  421 

arteriosclerotic  contracted,  411,  421 
atrophy  of,  granular,  411 
carcinoma  of,  423 
contracted,  411 

cyanotic,  401 

diagnosis,  413 

hypertrophy   of  myocardium  and, 
414 

pulse-tracing  of,  415 

symptoms,  413 

treatment,  416 
cyanosis  of,  22 

cyanotic  induration  of,  23,  401 
cystadenoma  of,  426 
cystic,  425 
diseases  of,  387 
dystopia  of,  432 
echinococcus  of,  427 
embolic  infarction  of,  420 
horseshoe,  432 
hypostatic,  401 

in  cardiac  insufficiency,  19 
large  white,  409 
movable,  428 

treatment,  431 
pelvis  of,  calculi  in,  441 
treatment,  446 

carcinoma  of,  447 

dilatation  of,  435 
treatment,  438 
varieties,  437 

diseases  of,  435 

inflammation  of,  438 

parasites  of,  448 
sarcoma  of,  425 
spotted,  contracted,  413 
suppuration  of,  416 

treatment,  420 
surgical,  417 

venous  hyperemia  of,  401 
wandering,  264,  428 

incarceration  of,  430 

treatment,  431 

Labia  inajora,  neuralgia  of,  524 
ivaennec's  cirrhosis  of  liver,  333 
Lagophthalmos,  paralytic,  481 
Laryngeal  cough,  95 
mucous  membrane,  anesthesia  of,  95 
sensory  disorders  of,  95 
Laryngitis,  catarrhal,  79 
treatment,  83 
granular,  82 
hemorrhagic,  81 
Larynx,  abscess  of,  85 
catarrh  of,  79 

treatment,  83 
disease  of,  79 


Larynx,  disease  of,  edema  of  glottis  and, 
86 
hyperesthesia  of,  95 
muscles  of,  paralysis  of,  89 

treatment,  92 
mycosis  of,  96 
pachydermia  of,  82 
papillomata  of,  83,  84 
paresthesia  of,  95 
perichondritis  of,  87 
polypi  of,  83,  84 
ulcers  of,  treatment,  84 
Lead-paralysis,  536 
Leptothrices,  pulmonary,  101 
Leukomyelitis,  554 

chronic,  558 
Leukoplakia  oris,  181 
Lientery,  245,  254 
Little's  disease,  581 
Liver,  abscess  of,  327 
treatment,  330 
adenoma  of,  350 
adipose,  342 
amyloid,  343 

atrophy  of,  acute  yellow,  338 
treatment,  341 
cryptogenetic,  339 
granular,  332 
blood-vessels  of,  diseases  of,  368 
carcinoma  of,  345 
treatment,  350 
cast  of,  325 
cirrhosis  of,  331 

alcoholic,  332,  334-336 
arteriosclerotic,  334,  338 
atrophic,  332 
diagnosis,  334 
hypertrophic,  332 
biliary,  333,  337 
Laennec's,  333 
monocellular,  334 
monolobular,  333 
multilobular,  333 
senile,  334,  378 
symptoms,  334 
syphilitic,  334,  337 
treatment,  338 
constricted,  355 

contracted,   331.     See  also  Liver,  cir- 
rhosis of. 
diseases  of,  315 
displacements  of,  355 
echinococcus  of,  350 

treatment,  355 
fatty,  342 

degeneration  of,  342 
infiltration  of,  342 
fissured,  355 
hypostatic,  323 

in  cardiac  insufficiency,  20 
induration  of,  cyanotic,  23 


G20 


INDEX  TO    VOLUME  I. 


Liver,  mold  of,  325 
movable,  355 
nutmeg,  323,  324 

cyanotic,  23 
sarcoma  of,  350 

serous  coat  of,  inflammation  of,  325 
suppurative  inflammation  of,  327 

treatment,  330 
syphilitic  lobulated,  334 
venous  hyperemia  of,  323 
wandering,  355 
Localization,  sense  of,  526 
Locomotor  ataxia,  572.     See  also  Tahes 

dorsalis. 
Lower  extremities,  muscular  spasm  in, 

513 
Lung,  abscess-formation  of,    bronchiec- 
tasis and, 108 
atelectasis  of,  121 
brown  induration  of,  22 
carcinoma  of,  149 
catarrhal  inflammation  of,  125 

treatment,  128 
cirrhosis  of,  139 
treatment,  142 
diseases  of,  117 
echinococcus  of,  151 
edema  of,  123 
agonal,  124 
emphysema  of,  alveolar,  117 
bronchiolitis  and,  118 
complications,  119 
treatment,  120 
interstitial,  120 
vicarious  alveolar,  119 
fibrinous  inflammation   of,  128.     See 

also  Pneumonia,  fibrinous. 
gangrene  of,  144 
complications,  147 
treatment,  148 
hypostasis  of,  122 
new-growth  of,  149 
sarcoma  of,  149 
slaty  induration  of,  140 
suppuration  of,  142 
tumors  of,  149 

Male,  impotence  in,  463 

sexual  organs,  diseases  of,  463 
sterility  in,  464 

Mammary  gland,  neuralgia  of,  521 

MarechaFs    test    for    biliary    coloring- 
matter,  319 

Mastication,  muscles  of,  paralysis  of,  476 
spasm  of  muscles  of,  507 

Masticatory  spasm,  507 

Mastodynia,  521 

Median  nerve,  paralysis  of,  495 

Mediastinitis,  173 

Mediastinopericarditis,  53 

Mediastinum,  abscess  of,  174 


Mediastinum,  diseases  of,  171 
inflammation  of,  173 
interstitial  eunihysema  of,  174 
tumors  of,  171 
Megalogastria,  229 
Megastomum  entericum,  293 
Melanosis,  villous,  253 
Melasicterus,  318 
Melena  of  newborn,  288 
Meningeal  hemorrhage,  607 
Meninges,  spinal,  diseases  of,  <101 

neoplasms  of,  609 
Meningitis,  cerebrospinal,  604 
purulent,  in  pneumonia,  13G 
spinal,  603 
acute,  603 
chronic,  606 
Merycism,  237 

Mesenteric  artery,  embolism  of,  43 
Miners'  anemia,  311 
Miserere,  273,  280 

Mitral  insufficiencj'  with   valvular  dis- 
ease, 39 
obstruction  M'ith  valvular  disease,  40 
stenosis  with  valvular  disease,  40 
Molimina,  hemorrhoidal,  286 
Morbus  coeruleus,  46 
Morvan's  disease,  567 
Motor   nerves,   spasmodic  disorders  of, 
507 
inflammation  of,  533 
trigeminal  spasm,  507 
Mouth,  diseases  of,  175 
inflammation  of,  175 
thrush  of,  179 
jMulberry-calculi,  363,  441,  446 
Munich  beer-heart,  28 
Murmur,  bubbling,  166 

endocardial  and  pericardial,  56 
nun's,  313 
presystolic,  40 
Muscular  contraction,  fascicular,  591 

spasm,  507 
Musculocutaneous   nerve,   paralysis   of, 

498 
Mycosis  nasi,  79 

pharyngis  leptothricia,  190 
Mycotic  bronchial  plugs,  101 
Myelitis,  acute,  552 

anesthesia  with,  554 
ascending,  555* 
bed-sores  with,  556 
diagnosis,  556 
gangrene  of  skin  in,  555 
treatment,  557 
central,  554 
chronic,  558 
ascending,  559 
central,  558 
circumscribed,  554 
compression-,  569,  598 


INDEX  TO    VOLUME  I. 


621 


Myelitis,  diffuse,  554 
hemorrliagic,  553 
multiple,  554 
purulent,  553 
transverse,  554 
Myelomalacia,  inflammatory,  553 

necrotic,  553 
Myelomeningitis,  acute,  554 

chronic,  558 
Myocarditic  cicatrices,  31 
Myocarditis,  31 
chronic,  32 

aneurysm  after,  33 
treatment,  33 
varieties,  32 
Myocardium,  diseases  of,  17 
weakness  and,  21 
echinococcus  of,  34 
hyperirritability  of,  after  pericarditis, 

56 
hypertrophy  of,  and  contracted  kid- 
ney, 414 
inflammation  of,  31 
tumors  of,  33 
weakness  of,  17 

and  dilatation  of  heart,  27 
diseases  and,  21 
in  pericarditis,  55 
senile,  22 
toxic  varieties,  22 
treatment,  23 
venous  stasis  with,  42 
Myomalacia  cordis,  31 
Myosis,  uremic,  397 
Myositis  from  trichinae,  307 

Narcosis,  carbon-dioxid,  127 
Nasal   mucous    membrane,   catarrh  of, 
from  coryza,  75 
fibrinous  inflammation  of,  77 
fungi  on,  79 
molds  on,  79 
Neck,   inferior  subcutaneous  nerve  of, 

neuralgia  of,  519 
Nematheliminthes,  301 
Neoplasmata  pericardii,  60 
Nephritis,  acute  desquamative,  404 
lymph omatous,  404 
chronic  hemorrhagic,  410 
interstitial,  411 
diagnosis,  413 
pulse-tracing  of,  415 
symptoms,  4l3 
treatment,  416 
parenchvmatous,  409 
diffuse,  402 
acute,  402 

pulse-tracings,  406 
treatment,  408 
urinary  sediments  from,  405 
purulent,  416 


Nephritis,  purulent,  cryptogenetic,  417 

treatment,  420 
Nephrolithiasis,  441 

diagnosis,  443 

symptoms,  443 

treatment,  446 
Nerve,  electric  irritability  of,  474 
Nerve-pain,  513 

Nerve-roots,  spinal,  changes  in,  in  tabes 
dorsalis,  574 
paralysis  of,  602 
Nervous  system,  diseases  of,  472 
Neuralgia,  513 

articular,  525 

cervicobrachial,  520 

cervico-occipital,  519 

crural,  521 

dorso-intercostal,  520 
anesthesia  with,  521 
hyperesthesia  with,  521 

glossalgia,  519 

in  aortic  aneurysm,  69 

infraorbital,  518 

lingual,  519 

lumbo-abdominal,  521 

malarial  form,  514 

neuritic,  514 

obturator,  522 

occipital,  519 

of  coccyx,  524 

of  external  cutaneous  nerves  of  thigh, 
522 

of  glans  penis,  524 

of  great  auricular  nerve,  519 

of    inferior    subcutaneous    nerve    of 
neck,  519 

of  labia  majora,  524 

of  mammary  gland,  521 

of  penis,  524 

of  perineum,  524 

of  scrotum,,  524 

of  supraclavicular  nerve,  520 

of  urethra,  524 

phrenic,  520 

sciatic,  522.     See  also  Sciatica. 

spermatic,  524 

supraorbital,  518 

syphilis  and,  514 

treatment,  519 

trigeminal,  516 

varieties,  514 
Neuritis,  531 

apoplectiform,  532 

ascending,  534 

hemorrhagic,  532 

interstitial,  532 

migratory,  532 

mixed,  532 

multiple,  534 

paralysis  with,  535 
recurrent,  536 


622 


INDEX  TO    VOLUME  I. 


Neuritis,  nodose,  532 

parenchymatous,  532 

segmental.  533 

suppurative,  532 

toxic,  536 

treatment,  534 
Neuron,  542 

cerebrospinal,  543 

of  second  degree,  543 
Neuroses,  cardiac,  61 
Newborn,  melena  of,  288 
Nictitation,  508 
Nocturnal  pollution,  466 
Nodes,  singers',  82 
Nose,  catarrh  of,  73 

chronic  atrophic.  75 

hypertrophic,  75 
complications,  74 
ozena  with,  76 
treatment,  76 

diseases  of,  73 
Nucleo-albumins  in  urine,  389 
Nun's  murmur,  313 
Nutmeg-liver,  323,  324 

cyanotic,  23 

Obstetric  paralysis,  499 

Obturator   nerve,    peripheral    paralysis 

of,  505  _ 
GEsophagomycosis  oidica,  203 
Oidium  albicans,  180 
Olfactory  nerve,  disease  of,  529 
Ox-heart,  27 

Oxyuris  vermicularis,  303 
Ozena  with  chronic  coryza,  76 

Pachtmexingitis,     spinal,    external, 
601 
internal,  602 
Pain-sense,  testing  of,  526 
Palate,   soft,  catarrh  of,  184.     See   also 
A  ngina. 
diseases  of,  184 
Palsy,  bandage-,  492 
coachmen's,  492 
crutch-,  492 
prisoners',  492 
water-carriers'.  492 
Pancreas,  calculi  in  ducts  of,  372 
carcinoma  of,  372 
cysts  of,  372 
diseases  of,  371 
fat-necrosis  in,  371 
hemorrhage  into,  371 
inflammation  of,  371 
Pancreatitis,  371 
Panum's  test  for  albumin,  389 
Parageusia,  531 

Paralysis,   acute  spinal,    of  childhood, 
583 
alcoholic,  539 


Paralysis,  arsenical,  538 
compression-,  spinal,  567 

general  paralysis  with,  569 
treatment,  571 
drummers',  493 
fright-,  601 

from  aortic  aneurysm,  69 
from  ergot-poisoning,  539 
lead-,  536 

motor,  of  trigeminal  nerve,  476 
narcosis-,  493 
obstetric,  499 
of  axillary  nerve,  498 
of  broad  dorsal  muscle,  503 
of  cerebral  nerves,  multiple,  490 
of  corrugator  muscle  of  eyebrow,  481 
of  diaphragm,  491 
of  elevator  of  angle  of  scapula,  503 
of  external  rotators  of  arm,  504 
of  facial  nerve,   477.     See  also  Facial 

nerve,  paralysiis  of. 
of  hypoglossal  nerve,  489 
of  iliopsoas  muscle,  505 
of  internal  rotators  of  arm,  503 
of  median  nerve,   495 
of  muscles  of  auricle,  482 
of  face,  478 
of  mastication,  476 
of  musculocutaneous  nerve,  498 
of  nerves  of  arms  and  brachial  plexus, 

493 
of  orbicular  muscle  of  eyelid,  481 
of  pectoral  muscles,  503 
of  phrenic  nerve,  490 
of  platysma  rayoides,  482 
of  radial  nerve,  492 
of  rhomboid,  503 
of  serrate  muscle,  500 
of  spinal  accessory  nerve,  488 

nerve-roots,  602 
of  sternocleidomastoid  muscle,  unilat- 
eral, 488 
of  tibial  nerve.  506 
of  tongue,  489 

of  trapezius  muscle,  488,  489 
of  ulnar  nerve,  497 
periodic,  507 
peripheral,  472 

muscular  contractions  in,  473 
of  abdominal  muscles,  504 
of  crural  nerve,  505 
of  gluteal  nerves,  506 
of  muscles  of  back,  504 
of  obturator  nerve,  505 
of  scapular  muscles,  500 
of  sciatic  nerve,  506 
treatment,  475 
pressure-,  476 
psvchic,  601 
reilex,  600 
saturnine,  536 


INDEX  TO    VOLUME  I. 


623 


Paralysis,  sleep-,  492 

spinal,  546 

acute  ascending,  599 
spastic,  581 

temporary,  584,  586 

uremic,  397 
Paranephritis,  432 

Pararenal  connective  tissue,  inflamma- 
tion of,  432 
Paratyphlitis,  257,  259 

diagnosis,  263 

symptoms,  263 

treatment,  266 
Parosmia,  530 

Pectoral  muscles,  paralysis  of,  503 
Pellagra,  paralysis  from,  539 
Penis,  neuralgia  of,  524 
Pepsin  in  gastric  juice,  209 
Peptones  in  urine,  389 
Pericardial  cavity,  gas  in,  58 

friction,  54 

synechige,  53 
Pericarditis,  52 

and  dilatation  of  heart,  57 

circumscribed,  53 

diagnosis,  55,  56 

difiuse,  52 

dry,  52 

external,  53 

hemorrhagic,  53 

humidn,  52,  53 

hyperirritability      of       myocardium 
after,  56 

myocardial  weakness  in,  55 

prognosis,  57 

purulent,  53 

putrid,  53 

serofibrinous,  53 

sicca,  52 

spontaneous,  52 

treatment,  57 

with  effusion,  52,  53 
Pericardium,    alterations   of  blood   in, 
60 

chyle  in,  60 

diseases  of,  52 

dropsy  of,  59 

inflammation  of,  52.     See  also  Peri- 
carditis. 

tumors  of,  60 
Perichondrium  of  larynx,  inflammation 

of,  87 
Pericystitis,  450 
Perihepatitis,  325 
Perimyelitis,  554 

chronic,  558 
Perineum,  neuralgia  of,  524 
Peripheral  disease  of  nerves  of  special 
sense,  529 

nerves,  degeneration  of,  474 
diseases  of,  472 


Peripheral  nerves,  inflammatory  and 
degenerative  disorders  of,  531. 
See  also  Neurilb^. 

paralysis,  472 

muscular  contractions  in,  473 
treatment,  475 
Peritoneum,  carcinoma  of,  386 

diseases  of,  372 

echinococcus  of,  386 

inflammation  of,  372.     See  also  Peri- 
tonitis. 
Peritonitis,  372,  375-380 

alimentary,  373 

by  extension,  373 

chronic,  symptoms,  379 

cryptogenetic,  373 

difl'use,  374,  375 

fatty,  383 

fibrinous,  374 

hemorrhagic,  375 

obliterative,  374 

perforative,  373,  377 

purulent,  374,  375 

])uti'id,  375 

rheumatic,  372 

serous,  374,  379 

suppurative,  374 

symptoms,  375-380 

traumatic,  372 

treatment,  380 
Perityphlitis,  257 

complications,  261 

diagnosis,  263 

symptoms,  260 

treatment,  264 
Peroneal  nerve,  palsy  of,  506 
Pettenkofer's   test  for  biliarv  coloring- 

mntter,  319 
Pharyngitis,  catarrhal,  184 

chronic  atrophic,  189 

circumscribed,  187 

complications,  187 

diffuse,  187 

granular,  188 

parenchymatous,  189 

superficial,  186,  188 

treatment,  189 
Pharynx,  catarrh  of,  184 

diseases  of,  184 
Phloroglucin-vanillin     solution,    Giinz- 

burg's,  207 
Phrenic  nerve,  paralysis  of,  490 
Phthisis  pituitosa,  101 

ventriculi,  213 
Pica,  240 
Piitis,  603 
Pilimictio,  458 

Platyhelminthes  in  intestine,  293 
Platysma  myoides,  paralysis  of,  482 
Plethora  and  fat  heurt,  30 
Pleura,  cachectic  edema  of,  169 


624 


INDEX  TO    VOLUME  I. 


Pleura,  carcinoma  of,  170 
diseases  of,  152 
dropsy  of,  169 
ecliinococcus  of,  171 
iutiamniation     of,     152.       See     also 
Pleurisy. 
Pleural  cavity,  blood  in,  170 
chyle  in,  170 
hypostatic  edema  of,  168 
exudates,   influence  on  other  organs, 
156 
Pleurisy,  152 

auscultation  in,  155 
cryptogenetic,  153 
diagnosis,  158 
diaphragmatic,  158 
dry,  153 
fibrinous,  153 
hemorrhagic,  153 
inspection  in,  154 
interlobular,  158 
moist,  153 
multilocular,  158 
palpation  in,  155 
percussion  in,  155 
pulsating,  158 
purulent,  153 

rupture  of  pus  in,  157 
serous,  153 
treatment,  160 
Pleuropneumonia,  fibrinous,  130 
Pneumatotherapy  for  pleurisy,  161 
Pneumococcus    of    bronchopneumonia, 
125 
of  Friinkel,  morphology,  128 
Pneumonia,  abortive,  134 
afebrile,  134 
aspiration-,  126 

in  perichondritis  of  larynx,  88 
asthenic,  135 
bilious,  135 
catarrhal,  125 

treatment,  128 
croupo\]s,  128.     See  also  Pneumonia, 

fbrinovK. 
dissecting,  140 
ephemeral,  134 
erratic,  135 
fibrinosa  cruciata,  131 

duplex,  131 
fibrinous,  128 

anomalies,    complications,   and  se- 

quelfe,  134 
delirium  in,  136 
diagnosis,  137 
incubation-period,  132 
of  children,  135 
prune-juice  sputum  in,  136 
symptoms,  132 
treatment,  138 
foreign-body,  126 


Pneumonia,  intermittent,  135 
interstitial,  139 

treatment,  142 
lobar,  1.30 
malignant,  135 
massive,  1.30 
progressive,  134 
protracted,  134 
pulmonary  abscess  after,  142 
recurrent,  135 
serous,  124 
totalis,  131 
typhoid,  135 
wandering,  135 
Pneumopericardium,  58 
Pneumoperitonitis,  375,  377 

sacculated,  378 
Pneumothorax.  162 
closed,  167 
diagnosis,  166 
ojien,  167 
transitional,  167 
treatment,  168 
valvular,  167 
Poikilocytosis,  313 
Poliomyelitis,  554 
anterior,  474,  542,  582 
chronic,  558 
of  adults,  586 
Pollution,  nocturnal,  466 

alarms  for,  467 
Polyneuritis,  534 
paralysis  with,  535 
recurrent,  536 
Portal  vein,  purulent  inflammation  of, 
370 
thrombosis  of,  368 
Precordium.  pains  in,  63 
Pressure-sense,  testing  of,  526 
Presvstolic  murmur,  40 
Proctitis,  244,  246 

chronic  catarrhal,  255 
Propeptones  in  urine,  389 
Prostatorrhea,  468 
Protozoa  in  intestine,  292 
Prune-juine  sputum  in  pneumonia,  136 
Pseudo-apoplectic  attacks  in  fat  heart, 

30 
Pseudocroup,  81 
Psorospasm,  508 
Ptvalism,  182 
false,  183 
idiopathic,  184 
primary,  184 
Puerperal  fever  and  endocarditis,  47 
Pulmonary  abscess.  142 

from  perichondritis  of  larynx,  88 
artery,  aneurysm  of,  152 
fistula,  166 

insufficiency  with  valvular  disease,  42 
obstruction  with  valvular  disease,  42 


INDEX  TO    VOLUME  I. 


625 


Pulmonary   orifice,    congenital    stenosis 
of,  45 
stenosis  witli  valvular  disease,  42 
Pulse,  cervical  venous,  conditions  mis- 
taken for,  41 
in  aortic  aneurysm,  68 
Pulsus  inspiratione  intermittens  s.  para- 
doxus, 112 
Pyelitis,  438 

and  iiydronephrosis,  440 
calculous,  442 
Pyelonephritis,  438 
suppurative,  417 
Pylephlebitis,  suppurative,  370 
Pylethrombosis,  368 
Pylorus,  incontinence  of,  237 
insufficiency  of,  237 
spasm  of,  236 
Pyonej)hrosis,  417 
Pyopericardium,  53 
Pyopneumopericardium,  58 
Pyopneumothorax,  162 

sacculated,  bronchiectasis  and,  109 
Pyramidal  tract,  anterior,  545 
crossed,  543 
direct,  545 
lateral,  543 
Pyrosis,  211 

Rachitis  and  spasm  of  glottis,  94 
Eadial  nerve,  paralysis  of,  492 
Eats,  trichinous,  306 
Reactionary  fever,  551 
Recurrent   laryngeal    nerves,    paralysis 
of,  91,  92 
from  carcinoma  of  esophagus, 
193 
Regurgitation,  nervous,  235 
Reumant,  anterolateral,  546 
Renal  artery,  aneurysm  of,  434 
em  hoi  ism  of,  43 
calculi,  441 

treatment,  446 
sand,  441 
Respiration  in  bronchial  catarrh,  99 
Respiratory  organs,  diseases  of,  73 
Retinal  artery,  embolism  of,  43 
Retinitis,  albuminuric,  415 
Rheumatism,  acute  articular,  and  endo- 
carditis, 50 
Rhinitis,  catarrhal,  73 
chronic  atrophic,  75 

hypertrophic,  75 
complications,  74 
ozena  with,  76 
treatment,  76 
fibrinous,  77 
Rhomboid  muscles,  spasm  of,  511 

paralysis  of,  503 
Robertson's  symptom,  575 
Rumination,  237 

40 


Salivation,  182 
Satiety,  disorders  of  sejise  of,  240 
Saturnine  paralysis,  536 
Scanning  speech,  561 
Scapula,  elevator  of  angle  of,   paralvsis 
of,  503 
spasm  of,  511 
Scapular  muscles,   peripheral  paralysis 

of,  500 
vScarlet  fever  and  verrucose  endocarditis, 

50 
Sciatic  nerve,   peripheral    paralvsis   of, 

506 
Sciatica,  522 
ascending,  523 
descending,  523 
neuritic,  523 
scoliotic,  523 

sugar  in  urine  in,  523 
Sclerosis,  amyotrophic  lateral,  593 
treatment,  596 
cerebrospinal,  multiple,  560 
nystagmus  in,  562 
treatment,  563 
Scrotum,  neuralgia  of,  524 
Seminal  fluid,  involuntary  discharge  of, 

465.     See  also  Spermalorrhea. 
Sensibility,  compasses  for  testing,  526 

cutaneous,  525 
Sensory  nerves,  inflammation  of,  533 
Seropneumopericardium,  58 
Seropneumothorax,  162 
Serrate  muscle,  paralysis  of,  500 
Sexual  organs,  male,  diseases  of,  463 
Sialodochitis,  fibrinous,  184 
Singers'  nodes,  82 
Singultus,  211 

Siphon,  stomach,  soft-rubber,  232 
Situs  viscerum  perversus  s.  inversus,  34 
Skin,  electric  sensibility  of,  526 
Slaty  induration  of  lung,  140 
Sleep-paralysis,  492 
Spasm,  muscular,  507 

rotatory,  511 
Spasmus  glottidis  ablactatorum,  94 
Spastic  rigidity  of  extremities,  581 
Spastic-paretic  gait,  581,  582 
Special  sense,  nerves  of,  peripheral  dis- 
ease of,  529 
Speech,  scanning,  561 
Spermatorrhea,  465 

charlatans'  treatment,  467 
permanent,  466 
true,  466 
Spinal  accessory  nerve,  paralysis  of,  488 
spasm,  510 
colinnn  and  dura   mater,  relation  of, 

541 
compression-paralysis,  567 
general  paralysis  with,  569 
treatment,  571 


626 


INDEX  TO    VOLUME  I. 


Spinal  cord,  abscess  of,  553 

acute    inflammation    of,   552.     See 

also  Myelitis,  acute. 
anatomy,  540 
anemia  of,  547 
anterior  horns  of,  542 

circumscribed  hemorrhage  into, 
551 
cavities  in,  5G4 
chronic  inflammation  of,  558 
columns  of,  diagram  of,  544 
diseases  of,  540 
asystematic,  547 
atypical,  547 
combined  system,  592 
divisions  of,  547 
rules  for  diagnosis,  541 
symjitoms,  546 
system,  572 
typical,  572 
functional  disorders  of,  599 
gray  matter  of,  541 
hemorrhages  into,  548 
circumscribed,  550 
treatment,  551 
tubular,  550 
hyperemia  of,  548 
in  hereditary  ataxia,  595 
neuroses  of,  599 
physiology,  540 

secondary  degeneration  of,  596-599 
single  system-diseases  of,  572 
soft  membranes  of,  inflammation  of, 

603-606 
softening  of,  553 
systems  of,  542 
transverse  lesion  of,  diagnosis,  570 

section  of,  542 
tumors  of,  564 
unilateral  lesions  of,  571 
white  matter  of,  541 
columns  of.  543 
dura  mater,  inflammation  of,  601 
membranes,  hemorrhage  into,  607 
meninges,  diseases  of,  601 

neoplasms  of,  609 
meningitis,  603 
acute,  603 

treatment,  606 
chronic,  606 
pachymeningitis,  external,  601 

internal,  602 
paralysis,  546 

acute  ascending,  599 
of  childhood,  583 
spastic,  581 
progressive  muscular  atrophy,  588 

treatment,  592 
sclerosis,    posterior,    572.      See    also 

Tahes  dorsalis. 
softening,  553 


Spleen,  infection-,  acute,  131 
Splenic  artery,  embolism  of,  43 
Splenius  muscle  of  head,  spasm  of,  511 
Sputum,  globular,  100 

prune-juice,  in  pneumonia,  136 
Sputum-cocci,  129 
Sputum-septicemia,  cocci  of,  129 
Stasis,  urine  of,  19 
Stenocardia,  63 
Stenosis,   aortic,  with  valvular   disease, 

38 
Sterility  in  male,  464 
Sternocleidomastoid   muscle,   unilateral 

paralysis  of,  488 
Sternomastoid,  spasm  of,  510 
Stimulants  in  cardiac  insufficiency,  24 
Stomach,  absorptive  power  of,  205 

ante-,  199 

atony  of,  238 

carcinoma  of,  222 
treatment,  226 

dilatation  of,  227 
treatment,  231 

yeast-cells  and  sarcinse  from  vomitus 
of,  230 

diseases  of,  205 

displacements  of,  233 

entire,  tonic  spasm  of,  236 

fungus  of,  223 

hypermotility  of,  236 

motor  activity  of.  206 

musculature  of,  tonic  spasm  of,  236 

nervous  tormina  of,  236 

neuroses  of,  234 
mixed,  241 
motor,  234 
secretory,  240 
sensory,  238 

peristaltic  unrest  of,  236 

suppurative  inflammation  of,  216 

ulcer  of,  latent.  218 
round, 217 

treatment,  220 
Stomach-contents,  acetic  acid  in,  209 

acidity  of,  207,  208 

butyric  acid  in,  209 

examination  of,  207 

hydrochloric  acid  in,  207 

lactic  acid  in,  209 

organic  acids  in,  209 
Stomach-siphon,  soft-rubber,  232 
Stomatitis,  aphthous,  178 

catarrhal.  175 

oidica.  179 

ulcerative,  177- 
Stomatomycosis  sarcinica.  181 
Stringhalt  gait,  577 
Struma,  substernal.  172 
Subacidity,  240 

Subarachnoid  hemorrhage,  608 
Subdural  hemorrhage,  608 


INDEX  TO    VOLUME  I. 


627 


Subpial  liemorrhage,  608 

Suffocation  in  perichondritis  of  larynx, 

88 
Superacidity,  240 

Supraclavicular  nerve,  neuralgia  of,  520 
Syncope,  total,  in  pleurisy,  157 
Syringomyelia,  564 

anesthesia  witli,  566 

atrophica,  566 

Tabes  dorsalis,  572 

absence  of  knee-jerk  in,  575 
ataxia  in,  576 
cervical,  575 
course  of,  579 

cutaneous  anesthesia  in,  577 
diagnosis,  580 
gastric  crises  in,  578 
gymnastics  for,  581 
intestinal  crises  in,  579 
paralysis  with,  579 
spinal  nerve-roots  in,  574 
syphilis  and,  572 
treatment,  580 
Tachycardia,  paroxysmal,  61 
Tactile  sensibility,  525 
Taenia  echinococcus,  350 

mediocanellata  s.  saginata,  293 
saginata,  297 
solium,  293,  299 
Tapeworms,  293 
heads  of,  299 
ova  of,  295 
proglottides  of,  295 
treatment,  298 
Temperature  sense,  testing  of,  526 
Tenesmus,  anal,  246 
Test,  Boedecker's,  for  albuminuria,  389 
boiling-nitric-acid,  388 
for  acidity  of  gastric  contents,  208 
for  albuminuria,  388 
four-glass,  210 
Galippe's  picric-acid,  389 
Gmelin's,  for  biliary  coloring-matter, 

319 
Heller's,  for  hematuria,  393 

nitric-acid,  389 
JaflTe's,  for  indican  in  urine,  281 
Marechal's,  for  biliary  coloring-mat- 
ter, 319 
Panum's,  for  albumin,  389 
Pettenkofer's,     for     biliary  coloring- 
matter,  319 
Test-breakfast,  207 
Test-meal,  206 
Thigh,   external     cutaneous   nerves   of, 

neuralgia  of,  522 
Thorax,   barrel-like,    in    emphvsema  of 
lungs,  118 
examination  of,  in  bronchial  asthma, 
114 


Thrush-fungus,  180 
Thyro-arv-epiglottic  muscles,  paralvsis 

of,  92 
Thyro-arvtenoid   muscles,  paralvsis  of, 

90 
Tibial  nerve,  paralysis  of,  506 
Tie,  rotatory,  511 
Tickling-sense,  testing  of,  526 
Time-sense,  testing  of,  526 
Tongue,  black,  182 

geographical,  182 

hairy,  ]82 

paralysis  of,  489 

spasm  of,  510 
Tormina,  nervous  intestinal,  290 

of  stomach,  236 
Torticollis,  605 
Trabecular  degeneration,  107 
Trachea,  diseases  of,  96 
Trapezius  muscle,  paralysis  of,  488,  489 

spasm  of,  510 
Tremor,  intention-,  561 
Trichina  spiralis,  305 
Trichinae,  muscle-,  305 
Trichiniasis,  305 

diagnosis,  310 

symptoms,  308 

treatment,  310 
Trichocephalus  dispar,  304 
Trichomonas  intestinalis,  293 
Tricuspid   insufficiency    with    valvular 
disease,  40 

obstruction  with  valvular  disease,  41 

stenosis  with  valvular  disease,  41 
Trigeminal,  motor  spasm  of,  507 

nerve,  distribution  of,  518 
motor  paralysis  of,  476 
Tunnel  anemia.  311 
Typhlitis,  257 

diagnosis,  263 

stercoral,  259 
symptoms,  262 
treatment,  265 
Typhoid  fever,  endocarditis  and,  49 

Uffelmann's  reagent,  209 
Ulcer,  fecal,  278 

stercoral.  278 
Ulnar  nerve,  paralysis  of,  497 
Uncinaria  duodenalis,  311 
Upper  extremities,  muscular  spasm  in, 

513 
Uremia,  396 

treatment.  400 
Uremides,  398 
Ureter,  carcinoma  of,  447 

diseases  of,  435 
Urethra,  neuralgia  of,  524 
Uridrosis,  398 

Urinary  bladder.     See  Bladder,  urinary. 
Urine,  albumin  in,  387 


628 


INDEX  TO    VOLUME  I. 


Urine,  albumin  in,  determination,  390 

albumoses  in,  389 

blood  in,  392 

icteric,  318 

indican  in,  Jaffe's  test  for,   281 

nucleo-albnmins  in,  389 

of  stasis,  19 

peptones  in,  389 

propeptones  in,  389 

sugar  in,  in  scoliotic  sciatica,  523 

unconscious  evacnation  of,  458 
Urocystitis,  448 

acute,  450 

chronic,  452 

croupous,  450 

hemorrhagic,  451 

mucous,  451 

pseudodiphtheric,  450 

pseudomembranous,  450 

suppurative,  451 

treatment,  453 

Vagus,  neurosis  of,  113 
Valvular  disease,  acquired,  35 

insufficiency,  relative,  35 
Ventricles,  dilatation   and  hypertrophy 
of,  24 
diagnosis  and  symptoms,  26 
hypeitrophy  of,  29 
Vermiform  appendix,  inflammation  of, 

257.     See  also  Appendicitis. 
Vertebra  prominens,  540 
Vertigo,  gastric,  214 
Vesicular  columns,  543 


Volvulus,  277 

Vomiting,  blood-,  in  newborn,  288 

fecal,  273,  280 

morning,  of  drunkards,  214 

nervous,  234 

periodic,  242 

"Wandering  kidney,  264 
AVeaning,  spasm  of  glottis  and,  94 
Westphal's  symptom  in  tabes  dorsalis, 

575 
White  matter  of  spinal  cord,  541 
Williams'  tracheal  note,  155 
Willisian  hyperacusis,  482 
Wintrich's  change  in  pitch,  164 
Worms,  flat,  sucking,  301 

tapeworms,  293 
of  intestine,  293 
round,  301 

Anguillula  intestinalis,  315 
stercoralis,  315 

Ankylostomum  duodenale,  311 

seat-"  303 

spool-,  301 

Trichina  spiralis,  305 

whip,  304 
Wry-neck,  605 

Xanthopsia,  320 

Yeast-cells  and  sarcinje  from  vomitus 

of  gastric  dilatation,  230 
Yellow  vision,  320 


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An  American  Text-Book  cf  Applied  Therapeutics. 

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An  American  Text-Book  qf  Diseases  qf  the  Eye,  Ear, 
Nose,  anb  Throat. 

Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Profes.sor  of  Ophthalmology, 
Jefferson  Medical  College,  Philadelphia ;  and  B.  Alexander  Randall, 
M.  D.,  Professor  of  Diseases  of  the  Ear,  University  of  Pennsylvania. 
Imperial  octavo,  1251  pages;  766  illustrations,  59  of  them  in  colors. 
Cloth,  ^7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.  So/d  by  Sub- 
scription. 


AIEDICA L   PL'BLICA TIONS 


An  American  Text-Book  qf  Genito- Urinary  and  Skin 
Diseases. 

Edited  by  L.  Bolton  Bangs,  M.  D.  ,  Professor  of  Genito-Urinary  Sur- 
gery, University  and  Bellevue  Hospital  Medical  College,  New  York ; 
and  W.  A.  Hardawav,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Mis- 
souri Medical  College.  Imperial  octavo  volume  of  1229  pages,  with  300 
engravings  and  20  full-page  colored  plates.  Cloth,  $7.00  net ;  Sheep  or 
Half  Morocco,  $8.00  net.      Sold  by  Subscription. 

An  American  Text-Book  qf  Gynecology,  Medical  and 

Surgical.       second  Edition.  Revised. 

Edited  by  J.  M.  Baldy,  M.  D.,  Professor  of  Gynecology,  Philadelphia 
Polyclinic,  etc.  Handsome  imperial  octavo  volume  of  718  pages;  341 
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§6.00  net;  Sheep  or  Half  Morocco,  $7- 00  net.     Sold  by  Subscription. 

An  American  Text- Book  qf  Legal  Medicine  anb  Toxi- 
cology. 

Edited  by  Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Ner\'Ous 
Department,  College  of  Physicians  and  Surgeons,  New  York ;  and 
Walter  S.  Haines,  M.  D.,  Professor  of  Chemistr}^  Pharmac}-,  and 
Toxicology,  Rush  Medical  College,  Chicago.     ///  Preparation. 

An  American  Text-Book  qf  Obstetrics. 

Edited  by  Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dick- 
inson, M.  D.  Handsome  imperial  octavo  volume  of  1014  pages; 
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net;   Sheep  or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

An  American  Text- Book  qf  Pathology. 

Edited  by  Ludwig  Hektoen,  M.  D.,  Professor  of  Pathology  in  Rush 
Medical  College,  Chicago  ;  and  David  Riesman,  M.  D.,  Demonstrator 
of  Pathologic  Histology  in  the  University  of  Pennsylvania.  ///  Press, 
Ready  Sho7'tly. 

An  American  Text-Book  qf  Physiology,    second  Edition. 

Revised,  in  Two  Volumes. 

Edited  by  William  H.  Howell,  Ph.  D.,  IM.  D.,  Professor  of  Physi- 
ology, Johns  Hopkins  University,  Baltimore,  Md.  Two  royal  octavo 
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An  American  Text-Book  qf  Surgery.    Third  Edition. 

Edited  by  William  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.);  and 
J.  William  White,  M.  D.,  Ph.  D.  Handsome  octavo  volume  of  1230 
pages;  496  wood-cuts  and  37  colored  and  half-tone  plates.  Thoroughly 
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gen  Rays  in  Surgery."  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
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OF   IV.  B.  SAUNDERS   &-    CO. 


THE  NEW  STANDARD  THE  NEW  STANDARD 

The  American  Illustrated  Medical  Dictionary. 

For  Practitioners  and  Students.  A  Complete  Dictionary  of  the  Terms 
used  in  Medicine,  Surgery,  Dentistry,  Pliarmacy,  Chemistry,  and  the 
kindred  branches,  including  much  collateral  information  of  an  encyclo- 
pedic character,  together  with  new  and  elaborate  tables  of  Arteries, 
Muscles,  Nerves,  Veins,  etc.  ;  of  Bacilli,  Bacteria,  Micrococci,  Strepto- 
cocci ;  Eponymic  Tables  of  Diseases,  Operations,  Signs  and  Symptoms, 
Stains,  Tests,  Methods  of  Treatment,  etc.,  etc.  By  W.  A.  Newman 
DoRLAND,  A.M.,  M.  D.,  Editor  of  the  "American  Pocket  Medical 
Dictionary."  Handsome  large  octavo,  nearly  800  pages,  bound  in 
full  flexible  leather.     Price,  $4.50  net;   with  thumb  index,  $5.00  net. 

Gives  a  Maximum  Amount  of  Matter  in   a    Minimum   Space   emd   at  the  Lowest 

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This  is  an  entirely  new  and  unique  work,  intended  to  meet  the  need  of  practitioners  and 
students  for  a  complete  up-to-date  dictionary  of  moderate  price.  It  contains  more  than  twice 
the  material  in  the  ordinary  students'  dictionary,  and  yet,  by  the  use  of  a  clear,  condensed 
type  and  thin  paper  of  the  finest  quality,  it  forms  an  extremely  handy  volume  only  i^  inches 
in  thickness.  It  is  a  beautiful  specimen  of  the  bookmaker's  art.  It  is  bound  in  full  flexible 
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important  terms  not  to  be  found  in  any  other  dictionary.  It  is  especially  full  in  the  matter 
of  tables,  containing  more  than  a  hundred  of  great  practical  value.  An  important  feature 
of  the  book  is  its  handsome  illustrations  and  colored  plates  drawn  especially  for  the  work, 
including  new  colored  plates  of  Arteries,  Nerves,  Veins,  Bacteria,  Blood,  etc. — twenty-four  in 
all.     This  new  work  has  been  aptly  termed  by  a  competent  critic  "  The  New  Standard." 

The  American  Pocket  Medical  Dictionary.    '^^J  ^^'*^°"' 

Revised. 

Edited  by  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to 
the  Hospital  of  the  University  of  Pennsylvania ;  Fellow  of  the  Amer- 
ican Academy  of  Medicine.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges.     Price  $1.00  net;  with  thumb  index,  $1.25  net. 

The  American  Year-Book  of  Medicine  and  Surgery. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and  investi- 
gators. Arranged  with  critical  editorial  comments,  by  eminent  Amer- 
ican specialists,  under  the  editorial  charge  of  George  M.  Gould,  M.  D. 
Year-Book  of  1901  in  two  volumes — Vol.  I.  including  General  Medicme; 
Vol.  II.,  General  Surgery.  Per  volume :  Cloth,  $3.00  net;  Half  Mo- 
rocco, ^3.75   net.      Sold  by  Subsci-ipfion. 

Abbott  on  Transmissible  Diseases. 

The  Hygiene  of  Transmissible  Diseases :  their  Causation,  Modes  of 
Dissemination,  and  Methods  of  Prevention.  By  A.  C.  Abbott,  M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  311  pages,  with  numerous  illustrations.     Cloth,  $2.00  net. 


MEDICAL    PUBLICA  TIONS 


Anders*  Practice  cf  Medicine.     Fourth  Revised  Edition. 

A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  Hand- 
some octavo  volume  of  1292  pages,  fully  illustrated.  Cloth,  $5-50  net; 
Sheep  or  Half  Morocco,  S6.50  net. 

Bastings  Botany. 

Lalioratory  Exercises  in  Botany.  By  Edson  S.  Bastix,  ]M.  A.,  late 
Professor  of  Materia  Medica  and  Botany,  Philadelphia  College  of 
Pharmacy.     Octavo,  536  pages,  with  87  plates.     Cloth,  S^-oo  net. 

Beck  on  Fractures. 

Fractures.  By  Carl  Beck,  M.  D.,  Surgeon  to  St.  ]Mark's  Hospital  and 
the  New  York  German  Poliklinik,  etc.  With  an  appendix  on  the  Prac- 
tical Use  of  the  Rontgen  Rays.  335  pages,  170  illustrations.  Cloth, 
S3-50  "et. 

Beck's  Surgical  Asepsis. 

A  iSIanual  of  Surgical  Asepsis.  By  Carl  Beck,  M.  D.,  Surgeon  to  St. 
Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306  pages; 
65  text-illustrations  and  12  full-page  plates.      Cloth,  $1.25  net. 

Boisliniere*s    Obstetric   Accidents,   Emergencies,   an? 
Operations. 

Obstetric  Accidents,  Emergencies,  and  Operations.  By  L.  Ch.  Bois- 
LiNiERE,  M.  D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis  Medical 
College.      381  pages,  handsomely  illustrated.      Cloth,  S2.00  net. 

Bohm,  Davidoff,   and  Huber*s  Histology. 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Technic. 
By  Dr.  A.  A.  Bohm  and  Dr.  M.  vox  Davidoff,  of  Munich,  and 
G.  Carl  Huber,  M.  D.,  Junior  Professor  of  Anatomy  and  Director  of 
Histological  Laboratory,  L^niversity  of  Michigan.  Handsome  octavo 
of  503  pages,  with  351  beautiful  original  illustrations.     Cloth,  S3. 50  net. 

Butler's  Materia  Medica,  Therapeutics,  and  Pharma- 
cology.     Third  Edition.  Revised. 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Phamiacology. 
By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  of  Materia  Medica  and 
of  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
Octavo,  874  pages,  illustrated.  Cloth,  S4.00  net;  Sheep  or  Half  Mo- 
rocco, S5.00  net. 

Cerna  on  the  Newer  Remedies,    second  Edition,  Revised. 

Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications  and 
Modes  of  Administration.  By  David  Cerxa,  ]NL  D.,  Ph.  D.,  Demon- 
strator of  Physiology,  Medical  Department,  L"niversity  of  Texas.  Re- 
written and  greatly  enlarged.    Post-octavo,  253  pages.    Cloth,  si.oo  net. 


OF   W.  B.  SAUNDERS   i^    CO. 


Chapin  on  Insanity. 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.  D.,  LL.  D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane ;  Honoiar)- 
Member  of  the  Medico-Psychological  Society  of  Great  Britain,  of  the 
Society  of  Mental  Medicine  of  Belgium,  etc.  i2mo,  234  pages,  illus- 
trated.    Cloth,  j^i.25   net. 

Chapman's   Medical    Jurisprudence  and  Toxicology. 

Second  Edition,  Revised. 

Medical  Jurisprudence  and  lexicology.  By  Henry  C.  Chapman, 
M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence, 
Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55  illus- 
trations and  3  full-page  plates  in  colors.      Cloth,  $1.50  net. 

Church  and  Peterson's  Nervous  arid  Mental  Diseases. 

Second  Edition. 

Nervous  and  Mental  Diseases.  By  Archibald  Church,  M.  D.,  Pro- 
fessor of  Nervous  and  Mental  Diseases,  and  Head  of  the  Neurological 
Department,  Northwestern  University  Medical  School,  Chicago ;  and 
Frederick  Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department, 
College  of  Physicians  and  Surgeons,  New  York.  Handsome  octavo 
volume  of  843  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Sheep  or 
Half  Morocco,  $6.00  net. 

Clarkson's  Histology. 

A  Text-Book  of  Histology,  Descriptive  and  Practical.  By  Arthur 
Clarkson,  M.  B.,  C.  M.  Edin.,  formerly  Demonstrator  of  Physiology 
in  the  Owen's  College,  Manchester;  late  Demonstrator  of  Physiology 
in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages;  22  engravings 
and  174  beautifully  colored  original  illustrations.     Cloth,  $4.00  net. 

Corwin's  Physical  Diagnosis.    Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur  M. 
Corwin,  A.m.,  M.  D.,  Instructor  in  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago.     219  pages,  illustrated.     Cloth,  $1.25  net. 

Crookshank's  Bacteriology.     Fourth  Edition,  Revised. 

A  Text-Book  of  Bacteriology.  By  Edgar  M.  Crookshank,  M.  B., 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo,  700  pages,  273  engravings  and  22  original  colored 
plates.     Cloth,  $6.50  net;    Half  Morocco,  $7.50  net. 

DaCosta'S    Surgery.       Third  Edition.  Revised. 

Modern  Surgery,  General  and  Operative.  By  John  Chalmers  Da 
Costa,  M.  D.  ,  Profes.sor  of  Principles  of  Surgery  and  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia  ;  Surgeon  to  the  Philadelphia 
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illustrated.     Cloth,   S5.00  net;    Sheep  or  Half  Morocco,  $6.00  net. 

Enleo-g'ed  by  over  200  Pages,  with  more  than   100  New  Illustrations. 


MEDICAL    PUBLICATIONS 


Davis's  Obstetric  Nursing. 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics  in  Jefferson  Medical  College  and  the 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist  to  the  Phila- 
delphia Hospital.  i2mo  volume  of  400  pages,  fully  illustrated. 
Ready  Shortly. 

DeSchweinitz  on  Diseases  qf  the  Eye.   Third  Edition,  Revised. 

Diseases  of  the  Eye.  A  Handbook  of  Ophthalmic  Practice.  By  G. 
E.  DE  ScHWEiNiTZ,  M.  D.,  Profcssor  of  Ophthalmology,  Jefferson  Medi- 
cal College,  Philadelphia,  etc.  Handsome  royal  octavo  volume  of  696 
pages;  256  fine  illustrations  and  2  chromo-lithographic  plates.  Cloth, 
$4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

Dorland*s  Dictionaries. 

[See  American  Illustrated  Medical  Dictionary  and  American 
Pocket  Medical  Dictionary  on  page  3.] 

Dorland's  Obstetrics. 

A  Manual  of  Obstetrics.  By  W.  A.  Newman  Dorland,  M.  D.,  Assist- 
ant Demonstrator  of  Obstetrics,  University  of  Pennsylvania ;  Associate 
in  Gynecology,  Philadelphia  Polyclinic.  760  pages;  163  illustrations 
in  the  text  and  6  full-page  plates.     Cloth,  $2.50  net. 

Eichhorst*s  Practice  qf  Medicine. 

A  Text-Book  of  the  Practice  of  Medicine.  By  Dr.  Herman  Eichhorst, 
Professor  of  Special  Pathology  and  Therapeutics  and  Director  of  the 
Medical  Clinic,  University  of  Zurich.  Translated  and  edited  by  Augus- 
tus A.  EsHNER,  M.  D.,  Professor  of  Clinical  IMedicine,  Philadelphia 
Polyclinic.     In  Press.     Ready  Soon. 

Friedrich  and  Curtis  on  the  Nose,  Throat,  and  Ear. 

Rhinology,  Laryngology,  and  Otology,  and  Their  Significance  in  Gen- 
eral Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited  by  H. 
HoLBROOK  Curtis,  ^L  D.,  Consulting  Surgeon  to  the  New  York  Nose 
and  Throat  Hospital.     Octavo,  348  pages.     Cloth,  $2.50  net. 

Frothingham*s  Guide  for  the  Bacteriologist. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Frothingham, 
M.  D.  v.,  Assistant  in  Bacteriology  and  Veterinary  Science,  Sheffield 
Scientific  School,  Yale  University.     Illustrated.     Cloth,  75  cts.  net. 

Garrigues*  Diseases  qf  Women.     Third  Edition.  Revised. 

Diseases  of  Women.  By  Henrv  J.  Garrigues,  A.  AL,  M.  D.,  Gyne- 
cologist to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New 
York  City.  Octavo,  756  pages,  with  367  engravings  and  colored  plates. 
Cloth,  $4.50  net;   Sheep  or  Half  Morocco,  $5.50  net. 


OF    W.   B.  SAUNDERS   6-    CO. 


Gould  and  Pyle's  Curiosities  cf  Medicine. 

Anomalies  and  Curiosities  of  Medicine.  By  CiEOROE  M.  Gould,  M.  D., 
and  Walter  L.  Pyle,  M.  D.  An  encyclopedic  collection  of  rare  and 
extraordinary  cases  and  of  the  most  striking  instances  of  abnormality  in 
all  branches  of  Medicine  and  Surgery,  derived  from  an  exhaustive 
research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  octavo 
volume  of  968  pages  ;  295  engravings  and  12  full-page  plates.  Popular 
Edition.      Cloth,  S3. 00  net;  Sheep  or  Half  Morocco,  $4.00  net. 

Grafstrom's  Mechano-Therapy. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gymnastics). 
By  Axel  V.  Grafstrom,  B.  Sc,  M.  D.,  late  House  Physician,  City  Hos- 
pital, Blackwell's  Island,  New  York.  i2mo,  139  pages,  illustrated. 
Cloth,  lii.oo  net. 

Griffith    on    the    Baby.       second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Pennsylvania;  Phy- 
sician to  the  Children's  Hospital,  Philadelphia,  etc.  i2mo,  404  pages; 
67  illustrations  and  5  plates.     Cloth,  ^1.50  net. 

Griffith's  Weight  Chart. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania. 
25  charts  in  each  pad.     Per  pad,   50  cts.  net. 

Hart's  Diet  in  Sickness  and  in  Health. 

Diet  in  Sickness  and  Health.  By  Mrs.  Ernest  Hart,  formerly  Student 
of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School  of  Medi- 
cine for  Women ;  with  an  Introduction  by  Sir  Henry  Thompson, 
F.  R.  C.  S.,  M.  D.,  London.      220  pages.     Cloth,  $1.50  net. 

Haynes*  Anatomy. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.  D.,  Professor  of 
Practical  Anatomy  in  Cornell  University  Medical  College.  680  pages ; 
42  diagrams  and  134  full-page  half-tone  illustrations  from  original  photo- 
graphs of  the  author's  dissections.     Cloth,  ^2.50  net. 

Heisler's  Embryology. 

A  Text-Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor 
of  Anatomy,  Medico-Chirurgical  College,  Philadelphia.  Octavo  volume 
of  405  pages,  handsomely  illustrated.     Cloth,  ^2.50  net. 

Hirst's    Obstetrics.      second  Edition. 

A  Text-Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D.,  Professor 
of  Obstetrics,  University  of  Pennsylvania.  Handsome  octavo  volume 
of  848  pages  ;  618  illustrations  and  7  colored  plates.  Cloth,  $5.00  net; 
Sheep  or  Half  Morocco,  $6.00  net. 


MEDICAL   PUBLICATIONS 


Hyde  and  Montgomery  on   Syphilis  ant  the  Venereal 

Diseases.       second  Edition.  Revised  and  Greatly  Enlarged. 

Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde,  M.  D., 
Professor  of  Skin  and  Venereal  Diseases,  and  Frank  H.  Montgomery, 
M.  D.,  Associate  Professor  of  Skin,  Genito-Urinary,  and  Venereal  Dis- 
eases in  Rush  Medical  College,  Chicago,  111.  Octavo,  594  pages, 
profusely  illustrated.     Cloth,  §4.00  net. 

^e  International  Text-Book  of  Surgery,     in  Two  volumes. 

By  American  and  British  Authors.  Edited  by  ].  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Medi- 
cal School,  Boston  ;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  Lecturer 
on  Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex 
Hospital  Medical  School,  London,  Eng.  Yo\.  I.  Genera/  Surge?-)'. — 
Handsome  octavo,  947  pages,  with  458  beautiful  illustrations  and  9 
lithographic  plates.  Vol.  H.  Special  or  Regional  Surgery. — Handsome 
octavo,  1072  pages,  with  471  beautiful  illustrations  and  8  lithographic 
plates.  Sold  by  Subscription.  Prices  per  volume:  Cloth,  $5.00  net; 
Sheep  or  Half  Morocco,  $6.00  net. 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The  clini- 
cian and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satis- 
faction to  the  editors  as  it  is  a  gratification  to  the   conscientious  reader." — Annals  of  Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has  very 
many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors 
is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor  of  each 
writer  to  make  his  subject  clear  and  to  the  point.  To  tliis  end  particularly  is  tlie  technique 
of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up  to  date  in 
a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional  parts  of  the 
body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which  the  reader 
may  not  learn  something  new." — Medical  Record,  New  York. 

Jackson's  Diseases  qf  the  Eye. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  AL  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine.  i2mo  volume  of  535  pages,  with 
178  illustrations,  mostly  from  drawings  by  the  author.     Cloth,  S2. 50  net. 

Keating's  Life  Insurance. 

How  to  Examine  for  Life  Insurance.  By  John  ]\L  Keating,  ]\L  D., 
Fellow  of  the  College  of  Physicians  of  Philadelphia  ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages.     With  numerous  illustrations.     Cloth,  §2.00  net. 

Keen  on  the  Surgery  qf  Typhoid  Fever. 

The  Surgical  Complications  and  Sequels  of  Tvphoid  Fever.  By  Wm. 
W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  the  Principles 
of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College,  Phila- 
delphia, etc.    Octavo  volume  of  386  pages,  illustrated.    Cloth,  $3.00  net. 

Keen's    Operation    Blank.       second  Edition,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.,  Required  in  Vari- 
ous Operations.  Prepared  by  W.  W.  Keen.  M.  D.,  LL.  D.,  F.  R.  C.  S. 
(Hon.),  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surger}', 
Jefferson  Medical  College,  Philadelphia.  Price  per  pad,  blanks  for  fifty 
operations,  50  cts.  net. 


OF   W.  B.  SAUNDERS   &^    CO. 


Kyle  on  the  Nose  and  Throat,     second  Edition. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical  College, 
Philadelphia.  Octavo,  646  pages;  over  150  illustrations  and  6  litho- 
graphic plates.     Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  ^5.00  net. 

Laine's  Temperature  Chart. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.  D.  Size  8x131^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions,  Food, 
Remarks,  etc.  On  the  back  of  each  chart  is  given  the  Brand  treatment 
of  Typhoid  Fever.     Price,  per  pad  of  25  charts,  50  cts.  net. 

Levy,  Klemperer,  and  Eshner*s  Clinical  Bacteriology. 

The  Elements  of  Clinical  Bacteriology.  -  By  Dr.  Ernst  Levy,  Pro- 
fessor in  the  University  of  Strasburg,  and  Felix  Klemperer,  Privat- 
docent  in  the  University  of  Strasburg.  Translated  and  edited  by 
Augustus  A.  Eshner,  M.  D.,  Professor  of  Clinical  Medicine,  Philadel- 
phia Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  ^2.50  net. 

Lockwood*s  Practice  of  Medicine. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lockwood, 
M.  D.,  Professor  of  Practice  in  the  Woman's  Medical  College  of  the 
New  York  Infirmary,  etc.  935  pages,  with  75  illustrations  in  the  text, 
and  22  full-page  plates.     Cloth,  $2.50  net. 

Long's  Syllabus  of  Gynecology. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "An  American 
Text-Book  of  Gynecology."  By  J-  W.  Long,  M.  D.,  Professor  of  Dis- 
eases of  Women  and  Children,  Medical  College  of  Virginia,  etc.  Cloth, 
interleaved,  $1.00  net. 

Macdonald's  Surgical  Diagnosis  and  Treatment. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.  D. 
Edin.,  F.  R.  C.  S.  Edin.,  Professor  of  Practice  of  Surgery  and  Clinical 
Surgery,  Hamline  University.  Handsome  octavo,  800  pages,  fully  illus- 
trated.     Cloth,  $5.00  net;   Sheep  or  Half  Morocco,  $6.00  net. 

Mallory  and  Wright's  Pathological  Technique. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work  in 
Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on  Post- 
Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank  B. 
Mallory,  A.  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.M., 
M.  D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.      Octavo,  396  pages,  handsomely  illustrated.      Cloth,  $2.50  net. 

McFarland's  Pathogenic  Bacteria.  '"'t^i^y^'^Z'lZT::!'^ 

Text-Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFarland, 
M.  D.  Professor  of  Pathology  and  Bacteriology,  Medico-Chirurgical 
College  of  Philadelphia,  etc.  Octavo  volume  of  621  pages,  finely  illus- 
trated.    Cloth,  $3.25  net. 


MEDICA  L    P UBLICA  TIONS 


Mei^s  on  Feeding  in  Infancy. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.  D.  Bound  in 
limp  cloth,  flush  edges,  25  cts.  net. 

Moore's  Orthopedic  Surgery. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.  D.,  Pro- 
fessor of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surger}-,  Uni- 
versity of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume 
of  356  pages,  handsomely  illustrated.     Cloth,  $2.50  net. 

Morten's  Nurses*  Dictionary. 

Nurses'  Dictionary  of  Medical  Terms  and  Nursing  Treatment.  Con- 
taining Definitions  of  the  Principal  Medical  and  Nursing  Terms  and 
Abbre^•iations  ;  of  the  Instruments,  Drugs,  Diseases,  Accidents,  Treat- 
ments, Operations,  Foods,  Appliances,  etc.  encountered  in  the  ward  or 
in  the  sick-room.  By  HoxxoR  Morten,  author  of  "  How  to  Become 
a  Nurse,"  etc.      i6mo,  140  pages.     Cloth,  Si. 00  net. 

Nancrede*s  Anatomy  anb  Dissection.    Fourth  Edition. 

Essentials  of  Anatomy  and  Manual  of  Practical  Dissection.  By  Charles 
B.  Naxcrede,  M.  D.,  LL.  D.,  Professor  of  Surgery  and  of  Clinical  Sur- 
ger}%  University  of  Michigan,  Ann  Arbor.  Post-octavo,  500  pages,  with 
full-page  lithographic  plates  in  colors  and  nearly  200  illustrations.  Extra 
Cloth  (or  Oilcloth  for  dissection-room),  $2.00  net. 

Nancrede's  Principles  qf  Surgery. 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede,  M.  D.^ 
LL.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of 
Michigan,  Ann  Arbor.    Octavo,  398  pages,  illustrated.    Cloth,  ^2.50  net. 

Norris*s  Syllabus  cf  Obstetrics.    Third  Edition.  Revised. 

Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department  of  the 
University  of  Pennsylvania.  By  Richard  C.  Norris,  A.M.,  M.  D., 
Instructor  in  Obstetrics  and  Lecturer  on  Clinical  and  Operative  Obstet- 
rics, University  of  Pennsylvania.  Crown  octavo,  222  pages.  Cloth,, 
interleaved  for  notes,  $2.00  net. 

Ogden  on  the  Urine. 

Clinical  Examination  of  the  L^rine  and  L'^rinar}-  Diagnosis.  A  Clinical 
Guide  for  the  L^se  of  Practitioners  and  Students  of  ISIedicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Instructor  in  Chemistry,  Harvard 
Medical  School.  Handsome  octavo,  41.6  pages,  with  54  illustrations 
and  a  number  of  colored  plates.     Cloth,  S3. 00  net. 

Penrose's  Diseases  qf  Women.    Third  Edition,  Revised. 

A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose,  M.  D., 
Ph.  D.,  formerly  Professor  of  Gynecolog}'  in  the  University  of  Penn- 
sylvania. Octavo  volume  of  531  pages,  handsomely  illustrated.  Cloth^ 
$3.75  net. 


OF   W.  B.  SAUNDERS  &    CO. 


Pryor — Pelvic  Inflammations. 

The  Treatment  of  Pelvic  Inflammations  through  the  Vagina.  By  W. 
R.  Pryor,  M.  D.,  Professor  of  Gynecology,  New  York  Polyclinic. 
i2mo,  248  pages,  handsomely  illustrated.     Cloth,  ;^2.oo  net. 

Pye*s  Banda£(ing. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  con- 
cerning the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter 
Pye,  F.  R.  C.  S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small 
i2mo,  over  80  illustrations.     Cloth,  flexible  covers,  75  cts.  net. 

Pyle's  Personal  Hygiene. 

A  Manual  of  Personal  Hygiene.  Proper  Living  upon  a  Physiologic 
Basis.  Edited  by  Walter  L.  Pyle,  M.  D.,  Assistant  Surgeon  to  the 
Wills  Eye  Hospital,  Philadelphia.  Octavo  volume  of  344  pages,  fully 
illustrated.      Cloth,  $1.50  net. 

Raymond's  Physiology. 

A  Manual  of  Phy.siology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital.  382  pages,  102  illustrations,  and  4 
full-page  colored  plates.     Cloth,  ^1.25  net. 

Salinger  and  Kalteyer*s  Modern  Medicine. 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College ;  and  F.  J.  Kalteyer, 
M.  D.,  Assistant  Demonstrator  of  Clinical  Medicine,  Jefferson  Medical 
College.     Handsome  octavo,  801  pages,  illustrated.     Cloth,  $4.00  net. 

Saundby's  Renal  and  Urinary  Diseases. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the 
Royal  Medico-Chirurgical  Society;  Professor  of  Medicine  in  Mason 
College,  Birmingham,  etc.  Octavo,  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  $2.50  net. 

Saunders'  Medical  Hand-Atlases. 

See  pages  1 6  and   1 7. 

Saunders'  Pocket  Medical  Formulary,  sixth  Edition.  Revised. 

By  William  M.  Powell,  M.  D.,  author  of  "Essentials  of  Diseases  of 
Children";  Member  of  Philadelphia  Pathological  Society.  Contain- 
ing 1844  formulae  from  the  best-known  authorities.  With  an  Appendix 
containing  Posological  Table,  Formulae  and  Doses  for  Hypodermic 
Medication,  Poisons  and  their  Antidotes,  Diameters  of  the  Female  Pelvis 
and  Fetal  Head,  Obstetrical  Table,  Diet  List  for  Various  Diseases,  Mate- 
rials and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from 
Drowning,  Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive 
Fevers,  etc.,  etc.  Handsomely  bound  in  flexible  morocco,  with  side 
index,  wallet,  and  flap.     $2.00  net. 

Saunders'  Question-Compends 

See  page  15. 


MEDICAL   P UBL ICA  TIONS 


Scudder'S    Fractures.       second  Edition.  Revised. 

The  Treatment  of  Fractures.  By  Chas.  L.  Scudder,  M.  D.,  Assistant 
in  Clinical  and  Operative  Surgery,  Harvard  University  Medical  School. 
Octavo,  460  pages,  with  nearly  600  original  illustrations.  Polished 
Buckram,  $4.50  net;    Hdlf  Morocco,  $5.50  net. 

Senn*s  Genito-Urinary  Tuberculosis. 

Tuberculosis  of  the  Genito-Urinary  Organs,  Male  and  Female.  By 
Nicholas  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of 
Surger)'  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.     Cloth,  $3.00  net. 

Senn*s  Practical  Surgery. 

Practical  Surgery.  By  Nichola.s  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Pro- 
fessor of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 
College,  Chicago.  Handsome  octa^•o  volume  of  over  1000  pages,  pro- 
fusely illustrated.      In  Press. 

Senn's  Syllabus  qf  Surg(ery. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged  in  con- 
formity with  "An  American  Text-Book  of  Surgery."  By  Nicholas 
Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Surger}^  and 
of  Clinical  Surgery,  Rush  Medical  College,  Chicago.     Cloth,  $1.50  net. 

Senn*S    Tumors.       second  Edition.  Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  Nicholas  Senn,  M.  D.  , 
Ph.  D.,  LL.  D.,  Professor  of  the  Practice  of  Surgery  and  of  Clinical 
Surgery,  Rush  Medical  College,  Chicago.  Octavo  volume  of  718  pages, 
with  478  illustrations,  including  12  full-page  plates  in  colors.  Cloth, 
$5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 

Starr's  Diets  for  Infants  and  Children. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.  By  Louis 
Starr,  M.  D.,  Editor  of  "An  American  Text-Book  of  the  Diseases  of 
Children."  230  blanks  (pocket-book  size),  perforated  and  neatly  bound 
in  flexible  morocco.      $1.25  net. 

Stengel's    Pathology.       Third  Edition.  Thoroughly  Revised. 

A  Text-Book  of  Pathology.  By  Alfred  Stengel,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania  ;  Visiting  Physician  to 
the  Pennsylvania  Hospital.  Handsome  octavo,  873  pages,  nearly  400 
illustrations,  many  of  them  in  colors.  Cloth,  5:5.00  net :  Sheep  or'Half 
Morocco,  $6.00  net. 

Stengel  and  White  on  the  Blood. 

The  Blood  in  its  Clinical  and  Pathological  Relations.  By  Alfred 
Stengel,  M.  D.,  Professor  of  Clinical  Medicine,  University  of  Penn- 
sylvania; and  C.  Y.  ^VHITE,  Jr.,  M.  D.,  Instructor  in  CHnical  Medicine, 
University  of  Pennsvlvania.      ///  Press. 


OF   W.  B.  SAUNDERS   d;^    CO.  13 

Stevens'  Materia  Medica  aiib  Therapeutics.  ^^TetS""' 

A  Manual  of  Materia  Medica  and  Therapeutics.  By  A.  A.  Stevkns, 
A.M.,  M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  University  of 
Pennsylvania.     Post-octavo,  445   pages.     Flexible  Leather,  ^2.00  net. 

Stevens*  Practice  qf  Medicine.    Fifth  Edition,  Revised. 

A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  University  of  Pennsyl- 
vania. Specially  intended  for  students  preparing  for  graduation  and 
hospital  examinations.  Post-octavo,  519  pages;  illustrated.  Flexible 
Leather,  $2.00  net. 

Stewart's    Physiology.       Fourth  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For  Students  and 
Practitioners.  By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc,  Professor  of 
Physiology  in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo 
volume  of  894  pages ;  T)-^6  illustrations  and  5  colored  plates.  Cloth, 
13-75  net. 

Stoney's  Materia  Medica  for  Nurses. 

Materia  Medica  for  Nurses.  By  Emily  A.  M.  Stoney,  late  Superintend- 
ent of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Boston, 
Mass.     Handsome  octavo  volume  of  306  pages.     Cloth,  $1.50  net. 

StOney's    Nursing.       second  Edition,  Revised. 

Practical  Points  in  Nursing.  For  Nm-ses  in  Private  Practice.  By  Emily 
A.  M.  Stoney,  late  Superintendent  of  the  Training-School  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass.  456  pages,  with  73  engravings 
and  8  colored  and  half-tone  plates.      Cloth,  $1.75  net. 

Stoney's  Surgical  Technic  for  Nurses. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  Emily  A.  M.  Stoney, 
late  Superintendent  of  the  Training-School  for  Nurses,  Carney  Hospital, 
South  Boston,  Mass.     i2mo  volume,  fully  ilhistrated.     Cloth,  ^1.25  net. 

Thomas's    Diet    Lists.       second  Edition,  Revised. 

Diet  Lists  and  Sick-Room  Dietary.  By  Jerome  B.  Thomas,  M.  D., 
Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  A^isiting  Physician  to  the  Kings 
County  Hospital.     Cloth,  $1.25  net.     Send  for  sample  sheet. 

Thornton's  Dose- Book  oTib  Prescription-Writing. 

Dose-Book  and  Manual  of  Prescription-A\'riting.  By  E.  Q.  Thornton, 
M.  D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia.     334  pages,  illustrated.      Cloth,  <;i-25  net. 

Van  V^lzah  and  Nisbet*s  Diseases  cf  the  Stomach. 

Diseases  of  the  Stomach.  By  William  W.  Van  Valzah,  M.  D.,  Pro- 
fessor of  General  Medicine  and  Diseases  of  the  Digestive  System  and 
the  Blood,  New  York  Polyclinic ;  and  J.  Douglas  Nisbet,  M.  D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive 
System  and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674 
pages,  illustrated.     Cloth,  $3.50  net. 


14  MEDICAL   PUBLICATIONS. 

Vecki's  Sexual  Impotence. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor  G. 
Vecki,  M.  D.  From  the  second  German  edition,  revised  and  enlarged. 
Demi-octavo,  291   pages.     Cloth,  g2.oo  net. 

Vierordt*s  Medical  Diagnosis.     Fourth  Edition.  Revised. 

Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medicine, 
University  of  Heidelberg.  Translated,  with  additions,  from  the  fifth 
enlarged  German  edition,  with  the  author's  permission,  by  Francis  H. 
Stuart,  A.M.,  M.  D.  Handsome  octavo  volume,  603  pages;  194 
wood-cuts,  many  of  them  in  colors.  Cloth,  ^4.00  net;  Sheep  or  Half 
Morocco,  $5.00  net. 

Watson's  Handbook  for  Nurses. 

A  Handbook  for  Nurses.  By  J.  K.  '\^"ATSON,  M.  D.  Edin.  American 
Edition,  under  super^'ision  of  A.  A.  Stevexs,  A.  M.,  M.  D.,  Lecturer 
on  Physical  Diagnosis,  University  of  Pennsylvania.  i2mo,  413  pages, 
73  illustrations.      Cloth,  $1.50  net. 

Warren's  Surgical  Pathology,     second  Edition. 

Surgical  Pathologv  and  Therapeutics.  By  John  Collins  Warren, 
M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surger}-,  Hanard 
Medical  School.  Handsome  octavo,  873  pages;  136  relief  and  litho- 
graphic illustrations,  ■x,},  in  colors.  With  an  Appendix  on  Scientific 
Aids  to  Surgical  Diagnosis,  and  a  series  of  articles  on  Regional  Bacte- 
riology.    Cloth,  $5.00  net;    Sheep  or  Half  ]Morocco,  $6.00  net. 


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"  Where  the  work  of  preparing  students'  manuals  is  to  end  we  cannot  say,  but  the  Saunders  Series, 
in  our  opinion,  bears  off  the  palm  at  present." — -Neiu  York  Medical  Record. 


1.  Essentials  of  Physiology.     A  new  work  in  preparation. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.D.     Seventh  edition,  revised,  with 

an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By  Charles   B.   Nancrede,   M.  D.     Sixth  edition,  thor- 

oughly revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorgemic.     By  Lawrence  Wolff, 

M.  D.      Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.  D.    Fourth  edition,  revised 

and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.     By  F.  J.  Kalteyer,  M.  D.     In 

preparation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  aind  Prescription-Writing.    By  Henry 

Morris,  M.  D.     Fifth  edition,  revised. 

8.  9-    Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Appendix 

on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition,  enlarged 
by  some  300  Essential  Formulae,  selected  from  eminent  authorities,  by  Wm.  M. 
Powell,  iSL  D.     (Double  number,  $1.50  net.) 

10.  Essentials  of  Gynecology.     By  Edwin  B.  Cragin,  M.  D.     Fourth  edition,  revised. 

11.  Essentials  of  Diseases  of  the  Skin.     By  Henry  W.  Stelwagon,  RL  D.     Fourth 

edition,  revised  and   enlarged. 

12.  Essentials  of  Minor  Surgery,  Bandaging,  eoid  Venereal    Diseases.     By  Edward 

Martin,  ]\L  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials    of    Legal    Medicine,   Toxicology,   euid    Hygiene.     This   volume   is   at 

present  out  of  prhit. 

14.  Essentials  of   Diseases    of   the  Eye,  Nose,  and  Throat.     By  Edward  Jackson, 

M.  D.,  and   E.  B.  Gli-:.ason,  ^L  D.     Second  edition,  revised. 

15.  Essentieds  of   Diseases   of  Children.     By  William   M.    Powell,  M.  D.     Second 

edition. 

16.  Essentials    of    Examination    of    Urine.     By    Lawrence   Wolff,   AL  D.      Colored 

'•  Vogel  Scale."     (75  cents  net.) 

YJ.   Essentials  of  Diagnosis.     By  S.   Solis-Cohen,   M.  D.,  and  A.   A.  Eshner,  M.  D. 

Second  edition,  thoroughly  revised. 

18.    Essentials    of    Practice    of    Pheirmacy.     By  Lucius    E.    Sayre.     Second   edition, 
revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  AL  V.  Ball,  JNL  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  InsEinity.     By  John  C.  Shaw,  M.D.     Third 

edition,  revised. 

22.  Essentials  of    Medical    Physics.      By  Fred  J.   Brockway,  AL  D.     Second  edition, 

revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  M.  D.,  and  Edward 

S.  Lawrance,  AL  D. 

24.  Essentials  of  Diseases  of  the  Em.     By   E.  B.   Gleason,   M.  D.     Second    edition, 

revised  and  greatly  enlarged. 

A  New  Volume. 

25.  Essentizds  of  Histology.     By  Louis  Leroy,  M.  D.     With  73  original  illustrations. 


Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 


Saunders'  Medical    Hand-Atlases. 


VOLUMES   NOW   READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshnkr, 
M.  D.,  Professor  of  Clinical  ^Medicine,  Philadelphia  Polyclinic.  With 
179  colored  figures  on  68  plates,  64  text-illustrations,  259  pages  of  text. 
Cloth,  $3.00  net. 

Atlas  of  Legal  Medicine. 

By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited  by  Frederick 
Peterson,  M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of 
Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates  and  193  beautiful  half-tone  illustrations.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx. 

By  Dr.  L.  Grunwald,  of  ^lunich.  Edited  by  Charles  P.  Gr.\vson, 
M.  D.,  Physician -in-Charge,  Throat  and  Nose  Department,  Hospital  of 
the  University  of  Pennsylvania.  With  107  colored  figures  on  44  plates, 
25  text-illustrations,  and  103  pages  of  text.     Cloth,  S2.50  net. 

Atlas  and  Epitome  of  Operative  Surgery. 

By  Dr.  O.  Zuckerkandl,  of  A'ienna.  Edited  by  J.  Chalmers 
DaCosta,  j\I.  D.,  Professor  of  Principles  of  Surger}-  and  Clinical  vSur- 
gerv,  Jefferson  ^Iedical  College,  Philadelphia.  AVith  24  colored  plates, 
217  text-illustrations,  and  395  pages  of  text.     Cloth,  S3. 00  net. 

Atlas   and   Epitome   of    Syphilis    and   the   Venereal 
Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton 
Bangs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  71  colored 
plates,  16  illustrations,  and  122  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweinitz,  M.  D., 
Professor  of  Ophthalmolog}-,  Jefferson  Medical  College,  Philadelphia. 
With  76  colored  illustrations  on  40  plates  and  228  pages  of  text. 
Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Skin  Diseases. 

By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
WAGON,  M.  D.,  Clinical  Professor  of  Demiatolog)^  Jefferson  Medical 
College,  Philadelphia.  With  63  colored  plates,  39  half-tone  illustra- 
tions, and  200  pages  of  text.      Cloth,  S3. 50  net. 

Atlas  and  Epitome  of  Special  Pathological  Histology. 

By  Dr.  H.  Durck,  of  :\Iunich.  Edited  by  Ludwig  Hektoen  M.  D., 
Professor  of  Pathologv,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  L  Readw  including  Circulator}',  Respirator}',  and  Gastro-intestinal 
Tract,  120  colored  figures  on  62  plates,  158  pages  of  text.  Part  IL 
Ready  Shortlx.     Price  of  Part  T.,  S3. 00  net. 

16 


Saunders'  Medical  Hand-Atlases. 


VOLUMES   JUST   ISSUED. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Translated  and  edited  with  addi- 
tions by  Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Department 
of  Corrections  and  to  the  Almshouse  and  Incurable  Hospitals,  New 
York.  With  40  colored  plates,  143  text-illustrations,  and  600  pages 
of  text.     Cloth,  $4.00  net. 

Atlas  and  Epitome  of  Gynecology. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  From  the  Seco?id  Revised  Ger- 
man Edition.  Edited  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gyne- 
cologist to  the  Methodist  Episcopal  and  the  Philadelphia  Hospitals ; 
Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored 
plates,  65  text-illustrations,  and  308  pages  of  text.     Cloth,  ^3.50  net. 

Atlas  and  Epitome  of  the  Nervous  System  and  its 
Diseases. 

By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Second  Re- 
vised German  Edition.  Edited  by  Edward  D.  Fisher,  M.  D.,  Pro- 
fessor of  Diseases  of  the  Nervous  System,  University  and  Bellevue 
Hospital  Medical  College,  New  York.  With  83  plates  and  a  copious 
text.     Cloth. 

Atlas   and   Epitome    of   Labor   and   Operative   Ob- 
stetrics. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  Fro7n  the  Fifth  Revised  German 
Edition.  Edited  by  J.  Clifton  Edgar,  M.  D.,  Professor  of  Obstetrics 
and  Clinical  Midwifery,  Cornell  University  Medical  School.  With  126 
colored  illustrations.     Cloth. 

Atlas    and    Epitome    of    Obstetrical    Diagnosis    and 
Treatment. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  Fi-om  the  Second  Revised  German 
Edition.  Edited  by  J.  Clifton  Edgar,  M.  D.,  Professor  of  Obstetrics 
and  Clinical  Midwifery,  Cornell  University  Medical  School.  72  colored 
plates,  numerous  text-illustrations,  and  copious  text.     Cloth. 


IN  PRESS  FOR  EARLY  PUBLICATION. 

Atlas  and   Epitome   of   Ophthalmoscopy  and    Oph- 
thalmoscopic  Dia£(nosis. 

By  Dr.  O.  Haae,  of  Zijrich.  From  the  Third  Revised  and  Enlarged 
German  Edition.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor 
of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  149 
colored  figures  and  82  pages  of  text. 


ADDITIONAL  VOLUMES   IN   PREPARATION. 

17 


CLASSIFIED  LIST 

OF  THE 

MEDICAL    PUBLICATIONS 


OF 


W.  B.  SAUNDERS  G  COMPANY 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Bblim,    DavidofF,    and    Huber — A  Text- 
Book  of  Histology- 

Clarkson — A  Text-Book  of  Histology 

Haynes — A  Manual  of  Anatomy,    .   . 

Heisler — A  Text-Book  of  Embryology 

Leroy — Essentials  of  Histology,  .    .    . 

Nancrede — Essentials  of  Anatomy,  . 

Nancrede — Essentials    of    Anatomy 
Manual  of  Practical  Dissection,  . 


and 


BACTERIOLOGY. 

Ball — Essentials  of  Bacteriolog}^ 15 

Crooksliaiik — A  Text-Book  of  Bacteriol- 
ogy   5 

FrotMngham — Laborator}' Guide,  ....  6 
Levy  and  Klemperer's  Clinical  Bacteri- 

olog\' 9 

Mallory  and  Wright— Pathological  Tech- 
nique   9 

McFarland — Pathogenic  Bacteria 9 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart 7 

Hart — Diet  in  Sickness  and  in  Health,  .    .  7 

Keen — Operation  Blank 8 

Laine — Temperature  Chart 9 

Meigs — Feeding  in  Early  Infancy 10 

Starr — Diets  for  Infants  and  Children,  .    .  12 

Thomas— Diet-Lists 13 

CHEMISTRY  AND  PHYSICS. 

Brockway — Essentials  of  Medical  Physics,  15 

Wolff — Essentials  of  Medical  Chemistry,  .  15 

CHILDREN. 
An  American  Text-Book  of  Diseases  of 

Children i 

Griffith— Care  of  the  Baby 7 

Griffith— Infant's  Weight  Chart 7 

Meigs — Feeding  in  Early  Infancy 10 

Powell — Essentials  of  Diseases  of  Children,  15 

Starr — Diets  for  Infants  and  Children,  .    .  12 

DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Diag- 
nosis         15 

Corwin — Physical  Diagnosis, 5 

Macdonald — Surgical  Diagnosis  and  Treat- 
ment   9 

Vierordt — Medical  Diagnosis 14 

DICTIONARIES. 

The  American  Illustrated  Medical  Dic- 
tionary   3 

The  American  Pocket  Medical  Dictionary,  3 

Morten — Nurses'  Dictionary 10 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases  of 

the  Eye,  Ear,  Nose,  and  Throat i 

De  Schweinitz — Diseases  of  the  Eye,    .    .     6 
Friedrich  and  Curtis — Rhinology,  Laryn- 
gology, and  Otolog}',  and  their  Signifi- 
cance in  General  Medicine, 6 

Gleason — Essentials  of  Diseases  of  the  Ear,    15 
Griinwald  and  Grayson — Atlas  of  Dis- 
eases of  the  Larynx 16 

Haah  and  De  Schweinitz — Atlas  of  Exter- 
nal Diseases  of  the  Eye, 16 

Jackson — Manual  of  Diseases  of  the  Eye,     8 
Jackson  and  Gleason — Essentials  of  Dis- 
eases of  the  Eye,  Nose,  and  Throat,  .    .    15 
Kyle — Diseases  of  the  Nose  and  Throat,  .      9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito-Uri- 

nary  and  Skin  Diseases 2 

Hyde  and  Montgomery — Syphilis  and  the 

Venereal  Diseases 8 

Martin — Essentials     of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,  ...  15 
Mracek  and  Bangs — Atlas  of  Syphilis  and 

the  \'enereal  Diseases 16 

Saundby — Renal  and  Urinary  Diseases,  .  .  11 
Senn — Genito-Urinary  Tuberculosis,  ...  12 
Vecki — Sexual  Impotence 14 


GYNECOLOGY. 

American  Text-Book  of  Gynecolog)' 
Cragin — Essentials  of  Gynecology,  . 
Garrigues — Diseases  of  Women,  . 
Long — Syllabus  of  Gynecology,  .  . 
Penrose — Diseasesof  Women, .  .  . 
Pryor — Pelvic  Inflammations,  .  .  . 
Schaeffer  and  Norris — Atlas  of  Gynecol 


15 
6 


17 


MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

An  American  Text-Book  of  Applied  Ther- 
apeutics,    I 

Butler— Text-Book    of    Materia    Medica, 

Therapeutics,  and  Pharmacology,   ...  4 

Cerna — Notes  on  the  Newer  Remedies,  .    .  4 
Morris — Essentials  of  Materia  Medica  and 

Therapeutics 15 

Saunders'  Pocket  Medical  Formulary,  .    .  11 

Sayxe — Essentials  of  Pharmacy 15 

Stevens — Manual  of  Therapeutics 13 

Stoney — Materia  Medica  for  Nurses,  ...  13 
Thornton — Dose-Book  and  Manual  of  Pre- 
scription-Writing   13 


MEDICAL  PUBLICATIONS  OF  IF.  B.  SAUNDERS  &-  CO.    19 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — M  e  d  i  c  a  1  Jurisprudence  and 
Toxicology 5 

Goletoiewski  and  Bailey — Atlas  of  Dis- 
eases Caused  by  Accidents 17 

Hofmann  and  Peterson — Atlas  of  Legal 
Medicine 16 

NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

■Cliapin — Compendium  of  Insanity,     ...      5 
Clmrch  and  Peterson — Nervous  and  Men- 
tal Diseases 5 

Shaw — Essentials  of  Nervous  Diseases  and 
Insanity 15 

NURSING. 

Davis — Obstetric  and  Gynecologic  Nursing,  6 

Griffith— The  Care  of  the  Baby 7 

Hart — Diet  in  Sickness  and  in  Health,   .    .  7 

Meigs — Feeding  in  Early  Infancy, 

Morten — Nurses'  Dictionary,    .    . 

Stoney — Materia  Medica  for  Nurses,      .    .  13 

Stoney — Practical  Points  in  Nursing,  ...  13 

Stoney — Surgical  Technic  for  Nurses,    .    .  13 

Watson — Handbook  for  Nurses,     ....  14 

OBSTETRICS. 
An  American  Text-Book  of  Obstetrics 
Ashton — Essentials  of  Obstetrics, 

Boisliniere — Obstetric  Accidents 4 

Borland — Manual  of  Obstetrics,      ....      6 
Hirst — Text- Book  of  Obstetrics, 
Norris — Syllabus  of  Obstetrics, 
Schaeffer  and  Edgar — Atlas  of  Obstetri- 
cal Diagnosis  and  Treatment,    .....    17 

PATHOLOGY. 
An  American  Text-Book  of  Pathology,    .     2 
Diirck  and  Hektoen — Atlas  of  Pathologic 

Histology .    16 

Kalteyer — Essentials  of  Pathology 15 

Mallory  and  Wright — Pathological  Tech- 
nique,  9 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 12 

Stengel — Text-Book  of  Pathology,    ...    12 
Warren — Surgical  Pathology  and  Thera- 
peutics,    14 

PHYSIOLOGY. 

An  American  Text-Book  of  Physiology,  2 

—  Essentials  of  Physiology 15 

Raymond — Manual  of  Physiology,     ...  11 

Stewart — Manual  of  Physiology 13 

PRACTICE  OF  MEDICINE. 

An  American  Year-Book  of  Medicine  and 
Surgery 3 

Anders — Text-Book  of  the  Practice  of 
Medicine 4 

Eichhorst — Practice  of  Medicine 6 

Lockwood — Manual  of  the  Practice  of 
Medicine, 9 

Morris — Essentials  of  Practice  of  Medi- 
cine  15 

Salinger  and  Kalteyer — Modem  Medi- 
cine  II 

Stevens — Manual  of  Practice  of  Medicine,    13 


SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 2 

Hyde  and  Montgomery — Syphilis  and  the 
Venereal  Diseases 8 

Martin —  Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,     .    .    15 

Mracek  and  Stelwagon — Atlas  of  Diseases 
of  the  Skin, 16 

Stelwagon — Essentials  of  Diseases  of  the 
Skin, 15 

SURGERY. 

An  American  Text-Book  of  Surgery,  .  .  2 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Beck — Fractures, 4 

Beck — Manual  of  Surgical  Asepsis,     ...  4 

Da  Costa — Manual  of  Surgery, 5 

International  Text-Book  of  Surgery,  .    .  8 

Keen — Operation  Blank 8 

Keen — The    Surgical    Complications   and 

Sequels  of  Typhoid  Fever 8 

MacdOnald — Surgical  Diagnosis  and  Treat- 
ment   9 

Martin —  Essentials    of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,      .    .  15 

Martin— Essentials  of  Surgery 15 

Moore — Orthopedic  Surgery 10 

Nancrede — Prmciples  of  Surgery 10 

Pye — Bandaging  and  Surgical  Dressing,     .  11 

Scudder — Treatment  of  Fractures,     ...  12 

Senn — Genito-Urinary  Tuberculosis,  ...  12 

!  Senn — Practical  Surgery, 12 

Senn — Syllabus  of  Surgery 12 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 12 

Warren — Surgical  Pathology  and  Thera- 
peutics   14 

Zuckerkandl  and   Da   Costa — Atlas    of 

Operative  Surgery 16 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical  Examination  of  the  Urine,  10 
Saundby — Renal  and  Urinary  Diseases,  .  11 
WolfiT — Essentials  of  Examination  of  Urine,    15 

MISCELLANEOUS. 

AbhOtt — Hygiene  of  Transmissible  Dis- 
eases  3 

Bastin — Laboratory  Exercises  in  Botany,  .      4 
Goletoiewski   and  Bailey — Atlas  of  Dis- 
eases Caused  by  Accidents 17 

Gould  and  Pyle — Anomalies  and  Curiosi- 
ties of  Medicine 7 

Grafstrom — Massage, 7 

Keating — How  to  Examine  for  Life  Insur- 
ance  8 

Pyle — A  Manual  of  Personal  Hygiene,  .  11 
Saunders'  Medical  Hand-Atlases,  .  .  16,17 
Saunders'  Pocket  Medical  Formulary,  .  .  11 
Saunders'  Question-Compends,  .  .  .  14,15 
Stewart    and   Lawrence — Essentials    of 

Medical  Electricity 15 

Thornton —  Dose-Book    and    Manual    of 

Prescription-Writing 13 

Van  Valzah  and  Nistoet — Diseases  of  the 
Stomach 13 


NOTHNAGEL'S   ENCYCLOPEDIA 

OF 

SPECIAL  PATHOLOGY  AND  THERAPEUTICS 


IT  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal 
jMedicine  ;  and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Ency- 
clopedia of  Special  Pathology  and  Therapeutics"  is  conceded  by  scholars  to 
be  without  question  the  best  System  of  Medicine  in  existence.  So  necessarj- 
is  this  book  in  the  study  of  Internal  Medicine  that  it  comes  largely  to  this  country 
in  the  original  German.  In  view  of  these  facts,  Messrs.  \V.  B.  Saunders  &  Com- 
pany have  arranged  with  the  publishers  to  issue  at  once  an  authorized  edition 
of  this  great  encyclopedia  of  medicine  in  English. 

For  the  present  a  set  of  some  ten  or  twelve  volumes,  representing  the  most 
practical  part  of  this  encyclopedia,  and  selected  by  a  competent  editor  with  espe- 
cial thought  of  the  needs  of  the  practical  physician,  will  be  published.  These 
volumes  will  contain  the  real  essence  of  the  entire  work,  and  the  purchaser  will 
therefore  obtain  at  less  than  half  the  cost  the  cream  of  the  original.  Later 
the  special  and  more  strictly  scientific  volumes  will  be  offered  from  time  to 
time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both 
English  and  German,  and  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to 
date,  and  the  American  edition  will  be  more  than  a  mere  translation  of  the  Ger- 
man ;  for,  in  addition  to  the  matter  contained  in  the  original,  it  will  represent  the 
very  latest  views  of  the  leading  Americeui  specialists  in  the  various  departments 
of  Internal  Medicine.  The  whole  System  will  be  under  the  editorial  super- 
vision of  a  clinician  of  recognized  authority,  who  will  select  the  subjects  for  the 
American  edition,  and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended 
over  a  number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming 
year,  and  the  remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume 
will  be  revised  to  the  date  of  its  publicatfon  by  the  American  editor.  This  will 
obviate  the  objection  that  has  heretofore  existed  to  systems  published  in  a  number 
of  volumes,  since  the  subscriber  will  receive  the  completed  work  while  the  earlier 
volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been 
to  compel  physicians  to  take  the  entire  System.  This  seems  vo  us  in  many  cases 
to  be  undesirable.  Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be 
given  the  opportunity  of  subscribing  for  the  entire  System  at  one  time  ;  but  any 
single  volume  or  any  number  of  volumes  may  be  obtained  by  those  who  do  not 
desire  the  complete  series.  This  latter  method,  while  not  so  profitable  to  the  pub- 
lisher, offers  to  the  purchaser  many  advantages  which  will  be  appreciated  by  those 
who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question, 
form  the  greatest  System  of  Medicine  ever  produced,  and  the  publishers  feel  con- 
fident that  it  will  meet  with  general  favor  in  the  medical  profession. 

20 


